Lethal Cardiac Rhythms - Manual Defibrillation

1. Resuscitation
CME Fall 2011

3. Agenda
• Morning
– Welcome & Introduction
– Housekeeping
– CPR Recert
– New Base Hospital Arrest Protocols
• Lunch & Flu shots

4. Agenda
• Afternoon
– Autopulse rounds presentation (Base Hospital)
– Dissection of Arrest ECGs
– Lethal Rhythms
– Manual Defibrillation
– Autopulse Plus (shock / synch)
– Skill Stations
– Test
• Go Home

5. New Training Tools
• Audience Response Systems
– ‘Clickers’
– Will be used for games, challenges, tests
• SimMan 3G
– State of the art patient simulator
– Allows us to practice in a safe environment
– Might seem spooky at first but great learning tool

6. Background
• Recent Changes in Resuscitation
– 2010 AHA ECC Guidelines
• Reduce interruptions to compressions
– Base Hospital Arrest Protocols
• Medical TORs
– Autopulse Plus (shock / synch)
• Minimizes pauses in CPR

7. Housekeeping
• New Woodstock General Hospital
– Emerg Patients enter through garage
• Garage holds 2 trucks
• 1st truck in, clear out quickly for next vehicle
• Caution leaving garage – blind corner to left
– Give report to RN at desk across from Trauma Rm
• Do not go behind desk – patient confidentiality
– Non-Emerg / Transfers
• Do Not Enter through Emerg / Garage
• Use side entrance, park trucks outside

9. TDMH
• When patching in give:
– Family MD (allows them time to contact doc)
– MRSA / VRE status if known (from MARS sheet)
• When arriving:
– Give health card to clerk with reason for visit
• Allows them to start registration
• Can help expedite tests, labs, x-rays, etc
• May not always be possible / practical (Code 4s)

10. All Hospitals
• When Patching give FRI status (+ve or –ve)
– Any new or worsening cough
– Shortness of Breath
– Fever over 38 deg C.
– Allows staff to prepare isolation precautions

11. IVs
• Please refrain from pre-spiking IV bags
– New drip set piece is sharp
– Causes bags to leak if pre-spiked
– Will most likely be switching to Baxter drip sets
• IV Locks
– Will probably start stocking locks
– Good for use when transporting to TDMH

12. ACRs
• Doing a great job uploading ECGs
• Procedures performed by 1 medic
– Unless its lifting, stairchair, extricate, etc
• Oxford policy – ACRs are completed for any
call where you arrive scene (even if no pt)
• Please don’t use ‘Z’ procedure codes (ie Z301)
• Will be placing OmniDrives in each truck soon
• Working on having ability to upload calls from
hospital or on the road

14. 2012 Base Hospital
New Arrest Protocols

15. Medical Arrests
• Introduction of Medical TOR Protocol
– ≥ 18 years
– Unwitnessed Arrest
– No ROSC
– No Shocks Delivered
> BHP Patch for TOR

16. Medical Arrests
• Introduction of EPI where Anaphylaxis is
suspected as the cause of arrest
– Give 0.01 mg/ kg to a max of 0.5 mg EPI 1:1000 IM

17. Traumatic Arrests
• Merging of Blunt and Penetrating Trauma
protocols
• > 30 days old
• VF/VT – 1 shock  ER
• Trauma TOR > 16 yrs
• Asystole – Patch for TOR
• PEA & Transport >30 mins – Patch for TOR

19. Autopulse Rounds
Dr. Sameer Mal - SWORBHP

20. Cardiac Arrest ECGs

25. LLeetthhaall RRhhyytthhmmss

27. Lethal Rhythms & Manual Mode
• Review of the 4 lethal rhythm types
• Nothing new, reviewed annually during
recerts
• Work on rapid recognition (5 seconds)

28. Lethal Rhythm

29. Ventricular Tachycardia
• 3 or more consecutive ventricular complexes
occurring at a rate of more than 100 bpm
• Could have an associated pulse or be pulseless

30. Ventricular Tachycardia
• Causes
– Usually starts suddenly, triggered by a PVC
– Usually a result of myocardial ischemia or
significant cardiac disease

31. Ventricular Tachycardia
• Other Causes
– Electrolytic imbalance (Acid/Base, Na+, K+…)
– CHF
– Stimulants (ETOH, tobacco, C8H10N4O2)
– Drug Toxicity (digitalis, trycylics, antidepressants)
– Sympathomimetics (cocaine, meth)
– Prolonged QT

32. Ventricular Tachycardia
• Interpretation
– QRS is WIDE
– ≥ 0.12 seconds (same as LBB interpretation)
– May appear distorted or bizarre
– P waves may or may not be present – if present
usually dissociated from QRS
– Rate > 100 bpm

33. Ventricular Tachycardia
• Types
– Monomorphic
- one form, derives from one focus
- every wave appears the same

34. Ventricular Tachycardia
• Types
– Polymorphic
- generated by multiple foci
- waveform appearance variable

35. Ventricular Tachycardia
• Types
ALS Warning:
Do NOT use
antidysrhythmic
drugs on Torsades
– Torsades de Pointes
- ‘twisting of the points’
- conduction rotates, form of polymorphic

36. Ventricular Tachycardia
• Action
– No Pulse?
– Fast?
– Wide?
SHOCK

37. Lethal Rhythm 2

38. Ventricular Fibrillation
• Chaotic ventricular rhythm results in
ventricular ‘quivering’ and pulselessness
• Always pulseless
• Most common initial rhythm in sudden cardiac
arrest

39. Ventricular Fibrillation
• Causes
– Myocardial ischemia
– AMI
– 30 AV block with a slow ventricular escape rhythm
– Cardiomyopathy
– Digitalis Toxicity
– Acidosis
– Electrolyte Imbalance
– Electrical Injury
– Drug Overdose (cocaine, tricyclics)

40. Ventricular Fibrillation
• Interpretation
– Chaotic
– No discernible P waves or QRS complexes

41. Ventricular Fibrillation
• Types
– Coarse VF
• Amplitude of > 3mm
– Fine VF
• Amplitude < 3mm
• May be very difficult to differentiate from asystole

42. Ventricular Fibrillation
• Action
SHOCK

43. Lethal Rhythm 3

44. Pulseless Electrical Activity
• Used to be called ‘Electromechanical
Dissociation’
• Electrical activity is present but there are no
resultant contractions

45. Pulseless Electrical Activity
• Causes – The 6 H’s and the 6 T’s
– Hypothermia
– Hypoxia
– Hydrogen ions (Acidosis)
– Hyper/Hypokalemia
– Hypoglycemia
– Hypothermia

46. Pulseless Electrical Activity
• Causes – The 6 H’s and the 6 T’s
– Tablets / Toxins (Drug overdose)
– Cardiac Tamponade
– Tension pneumothorax
– Thrombosis (MI)
– Thrombosis (PE)
– Trauma (Hypovolemia)

47. Pulseless Electrical Activity
• Interpretation
– Patient is pulseless, apneic
– Rhythm appears organized (anything from an
escape rhythm to normal sinus)
– Slow & Wide -> PEA
– Fast & Wide -> V Tach

48. Pulseless Electrical Activity
• Action
– Ensure Pulselessness
– Continue CPR

49. Lethal Rhythm IV

50. Asystole
• Flatline, absence of any electrical activity
• Causes – 6H’s, 6 T’s, prolonged VF / VT / PEA

51. Asystole
• Interpretation
Continue CPR
– Flat line
– Slow, wide, thin wave
– May be fine V-Fib
– Look at possible causes of death to help
differentiate from VF

52. Ventricular Escape Rhythms

53. Agonal Rhythms

54. Paced Rhythms

55. And now you know…
And Knowing is half the
battle

56. Manual Mode
Do not be afraid

57. Using the E Series in Manual
Mode
• Turn on Defib as you normally would
– Press ‘Manual Mode’ soft key

58. Using the E Series in Manual
Mode
• Turn on Defib as you normally would
– Then press ‘Confirm’ soft key

59. Using the E Series in Manual
Mode
• Ensure ‘Pads’ are selected (not Ld I,II or III…)

60. Using the E Series in Manual
Mode
• 120 Joules will be the default energy
• After shock is delivered, energy will increase
– 150 J, 200 J

61. Using the E Series in Manual
Mode
• To evaluate a rhythm
– Stop CPR
– Check Pulse
– NOT MORE THAN 5 SECONDS
– Press ‘Recorder’ button and print off
strip (also marks event on summary)

62. Using the E Series in Manual
Mode
• Resume CPR immediately
then make your
defibrillation decision
• (Shock / No Shock)
– You can use the rhythm strip
you printed to make the
decision after the pause

63. Using the E Series in Manual
Mode
• If choosing to shock, press
‘Charge’
– (no need to press ‘Analyze’)
– Confirm you have selected the
proper energy setting

64. Using the E Series in Manual
Mode
• Continue CPR until ready to shock then
once all rescuers are clear, press
‘Shock’ then resume CPR immediately.
– There should be a only very brief pause in
compressions

65. Using the E Series in Manual
Mode
To dump a shock, just hit the ‘Energy
Select’ button (either arrow)
If really unsure whether to shock or not,
the ‘Analyze’ button is always an
option.

66. Using the E Series in Manual
Mode
For Paeds
Keep Defib in Semi Automatic and use
pediatric attenuator pads

67. Autopulse Plus
AKA ‘Shock/synch’

69. Using Autopulse Plus
• The Autopulse now has the ability to
coordinate defibrillation with the contraction
cycle
• Allows for minimal interruption to
compressions
• Can be hooked up initially or at any point in
the call

70. Using Autopulse Plus

71. Using Autopulse Plus
• Connecting the Defib to the Autopulse
– Connector site is located at the top of the
Autopulse next to the battery bay

72. Using Autopulse Plus
• Connecting the electrodes to the Autopulse
– Connect the defib pad electrodes by plugging
them into the connector site (1)
– Ensure connector is firmly seated in the
connector site

73. Using Autopulse Plus
• Connecting Defibrillator to Autopulse
– Connect defibrillator cable into connector site
(marked ‘2’)
– Ensure cable is firmly seated

74. Using Autopulse Plus

75. Using Autopulse Plus
–When ready to interpret cardiac
rhythm, pause compressions briefly
for interpretation and pulse check if
applicable
–Resume compressions immediately

76. Using Autopulse Plus
• Ensure appropriate energy and charge
defibrillator if applicable
• Press ‘Shock’
– Shock may be delayed as long as 800 ms to
coordinate with the upstroke of compressions
from the Autopulse.

77. Using Autopulse Plus

78. Using Autopulse Plus

79. Using Autopulse Plus

80. Using Autopulse Plus