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56 Cards in this Set
- Front
- Back
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Cardiopulmonary Resuscitation (CPR) |
Manual stimulation of heart and lungs. |
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Defibrillation |
Delivery of electrical shock to stimulate heart back to normal rhythm. |
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Cardiovascular System |
The heart and blood vessels and circulation of the blood. |
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Acute Coronary Syndrome (ACS) |
Cardiac compromise - Any time the heart may not be getting enough oxygen.
Because signs and symptoms are so varied, tend to treat all patients with signs and symptoms as if they are having a heart problem. ( Leave diagnosis for hospital).
Signs & Symptoms: Chest Pain (crushing, dull, heavy, or squeezing) May deny pain but admit pressure. Discomfort Radiates to arm, upper abdomen or up to jaw. Left arm more than right. Difficulty breathing (Dyspnea) Anxious Impending doom Irritability and short temper. Nausea and pain or discomfort in upper abdomen. Vomit Less common loss consciousness. Sudden sweating Abnormal pulse or B/P Pulse abnormally slow Pulse abnormally fast Irregular pulse Fluttering sensation Hypotensive (below 90) Hypertensive (greater 140 or diastolic greater than 90) Pressure or pain in chest, difficulty breathing and history heart problems. Mild discomfort comes and goes. 1/4 to 1/3 do not have typical discomfort.
Have high level of suspicion and treat any patient with these signs for cardiac compromise.
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Patient Assessment |
1. Primary Assessment 2. Perform history OPQRST Past history SAMPLE 3. Physical Exam 4. Baseline Vitals
Look for following signs and symptoms: • Pain, pressure, or discomfort chest or upper abdomen • Difficulty breathing • Palpitations • Sudden sweating, nausea, or vomiting. • Anxiety • Unusual weakness • Abnormal pulse • Abnormal B/P |
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Patient Care
Acute Coronary Sundrome |
1. Place patient in position of comfort. Ask patient 2. Determine if oxygen should be given. Patient is hypoxic less 94% Are in distress Exhibit signs criticality (altered mental status, respiratory distress or pale skin) 3. Transport immediately with any of the following: No history of heart problems History but no nitroglycerin Systolic below 90-100 Only enough for 94% Res failure high- concentration BVM or pocket mask Low O2 sats get high-con above 94% Patients alert and not sig stress and O2 sat of at least 94% SHOULD NOT get O2. 4. If trained and equipped, 12 lead electrocardiogram. Can use thinners or catheter 5. Give patient nitroglycerin if following conditions are met: Chest pain History cardiac problems Physician has prescribed Has meds with him Systolic greater 90 to 100 Not taken viagra or similar within 48 to 72 hours Medical direction authorizes 6. After 1 dose give another in 5 min if following are met: No relief or partial relief Systolic still above 90to100 Medical direction authorizes Maximum of 3 doses - reassess after each dose. If B/P drops treat for shock. 7. Give Aspirin if following met: Chest pain Not allergic No history of asthma Not already on thinners No other contraindications Able to swallow Medical direction authorizes
When transport need to keep patient calm take into account for use of siren or horn. |
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Majority cardiac emergencies caused directly or indirectly by changes inner walls of the arteries. |
Problems with hearts electrical and mechanical also causes cardiac emergencies. |
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Coronary Artery Disease CAD (Special blood vessels coronary arteries) Supply O2 to heart. |
Buildup of fatty deposits in inner walls of the arteries.
Form deposits called Plaque
Calcium later causes hardening
Rough surface promotes clots
The clot and plaque form thrombus which can cause occlusion or break loose and form embolism which can occlude smaller vessels.
Areas downstream of occlusion die.
Blockage in heart is heart attack, in brain is stroke.
Risks of CAD that can be reduced: Hypertension Obesity Lack of exercise Elevated cholesterol and triglycerides. Smoking
Symptoms related to CAD Chest pain Angina Pectoris Acute Myocardial Infraction Heart Attack Congestive Heart Failure |
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Aneurysm |
Weak sections of arterial wall that dilate (balloon) are know as an aneurysm. If bursts rapid internal bleeding.
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Electrical Malfunctions of the Heart |
Dysrhythmia - An irregular or absent heart rhythm. Includes: Bradycardia Tachycardia Rhythms present no pulse Ventricular fibrillation Ventricular tachycardia Pulseless electrical activity Asystole (ceased electr) |
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Mechanical Malfunctions of the Heart |
Mechanical pump failure - death of a portion if the myocardium.
Deterioration or malfunction of the heart valves. |
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Angina Pectoris |
Literally Pain in the Chest
Myocardium starved if O2 results in chest pain. (Angina Attack)
Seldom lasts longer then 5 minutes.
Nitroglycerin is medication that dilates blood vessels, this leaves more blood in the veins, less blood back to the heart so less work for the heart to pump.
Patient usually can take 3 doses over 10 minutes. No results call for help.
EMT can give 3 doses in 5 min |
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Acute Myocardial Infraction (AMI) |
Portion of myocardium (heart muscle) dies due to lack if O2.
Sudden Death - cardiac arrest that occurs within 2 hours of symptoms.
Chronic respiratory problems, unusual exertion, or severe emotional stress may trigger an AMI.
Treatment includes fibrinolytics to dissolve clots blocking coronary arteries. Can use catheters.
Patients who leave hospital with AMI will usually be told to take aspirin daily.
Some are given beta blockers (Slow heart and make it beat less strongly). |
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Congestive Heart Failure CHF |
A condition of excessive fluid build up in the lungs and or other organs due to inadequate pumping of the heart.
Causes edema or swelling.
Congestion can also occur because aggregate failure of lung function.
Can be brought on by: Diseased heart valves Hypertension Obstructive pulmonary diseases (Emphysema...)
CHF often complication AMI
Progresses as follows: 1. Patient sustains an AMI 2. Damage left ventricle causes blood to back up in pulmonary circulation then in the lungs. (Pulmonary edema) 3. Left heart failure if not treated usually causes right heart failure. Right side becomes congested because lungs can not receive more blood. Fluids accumulate in extremities, liver, abdomen, feet and ankles (Pedal edema).
Signs and Symptoms CHF: Tachycardia Dyspnea Normal or elevated B/P Cyanosis Diaphoresis Pulmonary edema, sometimes frothy white or pink sputum. Anxiety from hypoxia Pedal edema Engorged neck veins Enlarged liver and spleen with abdominal distention. |
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Cardiac Arrest |
Odds of bringing back cardiac arrest patients has increased in last 15 to 20 years. |
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Chain of Survival |
1. Immediate recognition and activation. 2. Early CPR 3. Rapid Defibrillation 4. Effective ALS 5. Integrated post-cardiac arrest care.
Underlying theme teamwork.
High performance CPR requires a "pit crew". Fast deep CPR with minimal interruptions. EMTs are vital part of HP- CPR. |
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Early CPR |
Three ways to access early CPR 1. Get CPR professionals to patient quicker. 2. Train laypeople in CPR 3. Train dispatchers to instruct callers in CPR |
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High-Performance CPR |
• Compressing at least 2 inches • Allowing full relaxation on up stroke • Spending half if each compression on downstroke and half on the up stroke. • Using correct hand position • Spending no more then one second on each ventilation • Minimizing interruptions of CPR to no more than 10 secs. |
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Rapid Defibrillation |
Single most important factor.
If response time is longer than 8 minutes virtually no patients survive cardiac arrest.
Need to get defibrillators in the hands of layperson. |
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Effective Advanced Life Support |
Paramedics, who can intubate, give IVs, and administer medications.
EMT- Cardiac. EMT-Critical Care. EMT-Intermediate. Advanced EMT.
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Integrated Post-Cardiac Arrest Care |
Coordinating numerous different means of assessment and interventions that, together, maximize the patients chance of neurological intact survival.
Elements are: Adequate O2 Avoiding hyperventilation Performing 12 lead ECG Finding and managing treatable causes of the arrest Appropriate destination Inducing hypothermia Other advanced interventions |
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Controlled hypothermia |
Cooling patient to 90 to 93 degrees F and maintaining for 12 to 24 hours
Chilled intravenous saline
Cold packs on carotid arteries, femoral arteries, or armpits.
Cooling collar on carotid arteries. Cools brain first.
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Management of Cardiac Arrest |
Two links are early CPR and rapid defibrillation.
Need to be able to:
• Perform one or two man CPR • Use an automated external defibrillator • Request ALS • Use BVM with O2 • Use flow restricted O2 powered ventilation device • Lift and move patients • Suction a patients airway • Use airway adjunts • Take standard precautions BSI • Interview bystanders and family
Need to take defibrillator and have it close by. |
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Automated External Defibrillator AED |
Laws to make available in public places. |
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Types of AEDs |
Older method manual, requires analyzing of rhythm and determining shockable.
Automated external defibrillators, does analysis and determines shockable. |
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Automated External Defibrillators (Semi-Auto and Fully Auto) |
Semi-Auto require operator to push button to deliver shock.
Fully-Auto deliver shock automatically.
Mono phasic - delivers single shock.
Biphasic sends shock first in one direction than the other. Also typically measures impedance or resistance between pads and adjusts energy. Smaller and lighter. |
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How AEDs work |
AEDs distinguish between shockable and non shockable rhythms.
AEDs are designed only for patients in cardiac arrest.
Attach AEDs only to patients who unresponsive, pulseless, or non breathing.
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How AEDs work |
AEDs distinguish between shockable and non shockable rhythms.
AEDs are designed only for patients in cardiac arrest.
Attach AEDs only to patients who unresponsive, pulseless, or non breathing.
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Shockable rhythms: |
Ventricular fibrillation
Ventricular tachycardia |
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Ventricular Fibrillation VF |
Primary Electrical Disturbance
Shockable |
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Ventricular Tachycardia V-tach |
Less common
Fast heart beat that does not allow heart chamber to fill.
Shockable rhythm
Some patients are awake and have a pulse. These patients will show shockable on AED. Do not do it! |
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Non shockable rhythms: |
Pulseless Electrical Activity
Asystole |
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Pulseless Electrical Activity PEA |
Heart muscle fails and electrical rhythm remains normal. Muscle is terminally sick Patient lost to much blood Not shockable rhythm |
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Asystole |
Heart ceasing impulses all together.
Flatline
Non Shockable |
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VF and V-tach quickly deteriorate to asystole. |
Success depends on:
How quick laypeople recognize need for EMS and call 911
How quickly first responders arrive
How quick AED arrives
Age and general health of community. |
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Coordinating CPR and AED |
Do not touch patient during analysis and shock.
Stop CPR during analysis and shock, resume immediately.
Unwitnessed arrest:
Some stress defib before CPR
Two man - CPR until AED available. |
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Volume electrical shock |
Mono Phasic- 360 joules
Biphasic- 120 to 200 joules |
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Cardiac treatment sequence |
Verify arrest: Unresponsive Start CPR Turn AED on Apply AED/clear Analyze button Shock indicated Deliver shock No responses 2 min CPR Analyze button If SI give 1 more shock After 3 shocks transport No pulse, CPR transport NSI No shock indicated 2 min CPR Analyze button NSI 2 min CPR No pulse, CPR transport
May need to go back and forth between shock and non shock protocols.
Transport when following occur:
Administered 3 shocks 3 consecutive NSI Regains a pulse
Should not do more than 3 cycles of analyze, shock/no shock, and CPR before transport |
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Cardiac assessment: |
Scan breathing
Quick history HPI
Verify absence of pulse
Provide CPR while AED setup
Turn on AED
Apply pads to chest
Say clear
Press analyze
If advised press button
Perform CPR for 2 minutes (5 cycles) unless patient wakes up, moves, or begins to breath.
Gather additional information
Check pulse during CPR to determine effectiveness.
Direct insertion of airway
Direct ventilation with high concentration O2.
After 2 min CPR clear & analyze Check carotid artery ( max 10 sec)
If spontaneous pulse check breathing may still have to ventilate.
If breathing adequate you non rebreather with high con O2, if inadequate ventilate high O2 and transport.
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Patient assessment |
BSI important blood and fluids usually present.
Primary assessment:
If someone doing CPR have them stop.
No More than 10 sec to verify pulselessness Carotid), Apnea (no breathing), or agonal breathing (irregular, gasping). Look for other absence life signs and blood loss. If signs of life head tilt, and check breathing and pulse ABC. If lifeless perform CPR CAB sequence.
Resume CPR immediately
Gather history
Brief physical exam Onset Trauma Signs Symptoms
Decision points:
Are there signs of life Should I do CPR Or take ABC approach Do I have access to defib How will I integrate defib |
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Patient Care |
1. Begin or resume CPR 2. Apply AED Adult Child 3. Bare patients chest 4. Turn AED 5. Attach monitoring electrodes 6. Once attached stop all activity and analyze if NSI resume CPR 7. If shock administer shock 8. Immediately resume CPR 9. Reassess after 2 min (5 cycles): If patient awakes or moves, get baseline vitals, ensure high con O2 and transport. If ALS enroute wait or intercept. (CPR during transport not high quality) |
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When providing CPR |
1. Do not interrupt CPR for more than 10 seconds
2. Compressions at least 2 inches deep Adult - 2 inches Child - 2 inches Infant - 1.5 inches
3. Rate 100 per min
4. Rotation to prevent rescuer fatigue.
If patient does not have spontaneous circulation after 3 shocks or 2 consecutive NSI, prepare for transport. |
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Special considerations for AED use. |
One does defib over CPR
CPR must include high quality compressions.
Defrib comes first ( need quick analysis)
Must be familiar with model
All contact avoided during analysis.
State "Clear" before shock
Check batteries and defrib at shift start.
After 3 shocks transport
Stop vehicle to analyze
Do not check pulse during analysis |
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Guidelines for use of multi-AEDs |
Take first AED to hospital and analyze whether to change AED
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Post-Resuscitation Care |
1. If patient has pulse keep defrib attached, reassess often.
2. If no pulse, AED gives no shock or prompts to analyze, resume CPR.
3. Assure adequate ventilation, but do not hyperventilate or over oxygenate. Excessive 02 can do harm during reperfusion. Only need 94% |
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Patients who go back into cardiac arrest. |
Most who are resuscitated are unconscious and require ventilation.
Check pulse every 30 seconds
May get shockable notice from AED, if so, check pulse. If no pulse:
If en route stop vehicle
Start CPR if AED not ready
Analyze the rhythm
Deliver shock if indicated
2 shocks separated by 2 min of CPR |
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Has cardiac arrest in ambulance |
Stop vehicle and follow cardiac arrest protocols. |
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Single rescuer with AED |
Apply AED and defib immediately
After shock or NSI begin CPR
After 2 min CPR check rhythm shock if needed
Resume CPR 2 min, check rhythm one more time.
If still alone continue in this fashion. |
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Contraindications |
Only one in using defib if paddles won't fit without touching.
Sometimes defib not indicated in trauma. Most commonly caused by loss of blood.
Should do immediate transport.
Defib not always effective in hypothermia cases. Need core temp of at least 86 degrees.
Do defib patient soaking wet or touching metal that others are touching.
If nitroglycerin patch remove it |
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Pediatric note |
Cardiac arrest in infants most often caused by respiratory problems.
Aggressive airway management and ventilation is best course.
Better to use adult AED than to do CPR without it. |
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Implants and surgeries |
ABC, CPR, and O2 delivery will not change with rare exceptions. May have to adjust paddle placement.
Cardiac Pacemaker - place paddles several inches away
Malfunctioning pacemaker usually results in slow or irregular pulse. May have signs of shock.
Implant defib - no change in treatment.
Ventricular assist device- VAD because pressure is constant will not have pulse. Need to rely on consciousness and breathing. Do not defib without medical director permission.
Cardiac bypass surgery - same treatment as other patients. |
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Quality improvement |
Medical director Initial training Maintenance of skills Case review Trend analysis Strengthening chain survival
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Mechanical CPR Devises |
Lucas CPR device
Auto-Pulse |
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Lucas CPR Device |
Standard precautions Ensure CPR in process Stop only long enough to put plate under patient. Attach upper and start CPR Position suction cup lower edge just above lower end sternum. With machine in adjust position plate to just touch chest. Push active button Apply stable strap If termination or spontaneous vitals power down unit. |
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Auto-Pulse |
Standard precautions Ensure CPR in progress Align patient Close Lifeband chest band Press start Provide BVM After 2 min reassess |
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Terminating Resuscitation |
Once you start resuscitation you must continue until:
Spontaneous circulation occurs provide breathing Spontaneous circulation snd breathing occur. Another trained rescue take over Turn patient over to higher level of training. You are to exhausted to continue You receive a "No Resuscitate" order
Protocol for resuscitation termination: (all three must be present)
1. The arrest was not witnessed by EMS or first responders. 2. No return of spontaneous circulation after 3 rounds of CPR and defib 3. AED did not detect s shockable rhythm.
If you turn patient over that person must be trained at same or higher level.
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