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CARDIAC LIFE SUPPORT - EDITED.pptx
- 1. BY : AIMANAMINUDDIN BIN MOHD SHUHAIMI SUPERVISOR : DR RUZAINA CARDIAC LIFE SUPPORT – MEGACODE AND RHYTHM RECOGNITION
- 2. OUTLINES Introduction Pulselessarrest Shockable Non-shockable Tachy-arrythmia Brady-arrythmia Medications
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- 6. SINUS RHYTHM Regularrhythm. Normal P wave morphology and axis (upright in I and II, inverted in aVR). Narrow QRS complexes (< 100 ms wide). Each P wave is followed by a QRS complex. The PR interval is constant. ( P-R interval < 0.2sec )
- 7. ECG INTERVALS INTERVALS NORMALDURATION EVENTS ON HEART DURING INTERVALS PR INTERVAL 0.12-0.20s (3-5 small squares) Atrial depolarization and conduction through AV node QRS INTERVAL <0.12s Ventricular depolarization and atrial repolarization QT INTERVAL 0.38 – 0.42s Ventricular depolarization plus ventricular repolarization ST INTERVAL (QT - QRS) -Measured from J Point to end of the T Wave, represents the repolarisation of the ventricular tissue -Usually isoelectric 1. Elevation (>1mm) 2. Horizontal/isoelectric 3. Depression (>0.5mm) Ventricular repolarization
- 8. THE J POINT •J point – where the QRS complex and ST segment meet • ST segment elevation - evaluated 0.04 seconds (one small box) after J point
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- 12. PULSELESS ARREST Signs and symptomsof cardiac arrest : Unresponsive No breathing Gasping Agonal breathing Seizure
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- 14. 1. VENTRICULAR FIBRILLATION Chaotic irregular deflections of varying amplitude. No identifiable P waves, QRS complexes, or T waves. Rate 150 to 500 per minute. Amplitude decreases with duration (coarse VF-> fine VF).
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- 16. 2. PULSELESS VENTRICULAR TACHYCARDIA Very broad complexes (~ 200 ms). Regular ventricular rate. Possibly some superimposed P waves.
- 17. 3. PULSELESS ELECTRICALACTIVITY (PEA)
- 18. 3. PULSELESS ELECTRICALACTIVITY (PEA) Organized electrical activity other than VT with absence of pulse Pathophysiology: Cardiac conduction impulses occurs in organized pattern but this fails to produce myocardial contraction ; or insufficient ventricular filling during diastole ; or ineffective contraction.
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- 20. 4. ASYSTOLE Noventricular activity.
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- 24. TACHYARRYTHMIAS Rhythm withheart rate >100 bpm Has many potential causes May be symptomatic or asymptomatic The key management is to determine whether pulses are present or not If pulses are present, determine whether the patient is stable or unstable Tachycardia is HR > 100 beats/minute Tachyarrhythmia normally seen when HR > 150 beats/minute
- 25. SINUS TACHYCARDIA Heart rate> 100 bpm. Regular rhythm. P wave for every normal QRS complex P waves may be hidden within each preceding T wave at higher rate.
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- 27. SUPRAVENTRICULAR TACHYCARDIA Narrow complextachycardia P waves not seen. Rate > 150 bpm. Regular rhythm.
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- 29. ATRIAL FLUTTER Rhythmcan be regular or variable. Rapid identical undulating waves. No P waves. Sawtooth appearance known as flutter waves.
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- 31. ATRIAL FIBRILLATION Irregularlyirregular rhythm. No P waves. Absence of an isoelectric baseline. Variable ventricular rate. QRS complexes usually < 120 ms. Fibrillatory waves may mimic P waves leading to misdiagnosis.
- 32. POLYMORPHIC VT (TORSADESDE POINTES)
- 33. POLYMORPHIC VT (TORSADESDE POINTES) Rate 150 – 250 bpm. QRS showed continuous changing of axis (hence ‘turning of point‘). Prolonged QT interval. Irregular ventricular rhythm.
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- 38. SINUS BRADYCARDIA Sinus rhythm. A restingheart rate of < 60 bpm. Normal QRS complex
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- 40. FIRST-DEGREE AV BLOCK PR interval >200ms (five small squares). Sinus rhythm. Normal P wave followed by normal QRS complex. ‘Marked’ first degree block if PR interval > 300ms.
- 41. SECOND-DEGREE AV BLOCKMOBITZ TYPE I (WENKEBACH)
- 42. SECOND-DEGREE AV BLOCKMOBITZ TYPE I (WENKEBACH) Progressive prolongation of the PR interval culminating in a non-conducted P wave. The PR interval is longest immediately before the dropped beat. The PR interval is shortest immediately after the dropped beat.
- 43. SECOND-DEGREE AV BLOCKMOBITZ TYPE II
- 44. SECOND-DEGREE AV BLOCKMOBITZ TYPE II Intermittent non-conducted P waves without progressive prolongation of thePR interval (compare this to Mobitz I). The PR interval in the conducted beats remains constant. The P waves ‘march through’ at a constant rate. The RR interval surrounding the dropped beat(s) is an exact multiple of thepreceding RR interval (e.g. double the preceding RR interval for a singledropped beat, treble for two dropped beats, etc).
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- 46. THIRD-DEGREE AV BLOCK In complete heart block, there is complete absence of AV conduction – noneof the supraventricular impulses are conducted to the ventricles. Atrial and ventricular rate regular but indipendently dissociated. The P wave is normal.
- 48. DRUGS IN RESUSCITATION DRUGINDICATIONS DOSE AND ADMINISTRATION SIDE EFFECT AND PRECAUTIONS ADRENALINE • Cardiac arrest • Symptomatic bradycardia <40bpm • Severe hypotension • Anaphylaxis • IV/IO: 1mg ( 1 ml 1:1000 ), administered every 3- 5minutes followed by 20ml flush • For Anaphylactic Shock • Severe Hypertension • Tachyarrhythmias • Tissue necrosis if extravasation occurs ATROPINE • First line drug for symptomatic Bradycardia • Organophosphate poisoningSide • The recommended dose for bradycardia is 0.5mg IV every 3 to 5 minutes to amax total dose of 3mg• • Use atropine cautiously in the presenceof acute coronary ischemia or MI;increased heart rate may worsen ischemiaor increase infarction size.
- 49. DRUGS IN RESUSCITATION DRUGINDICATIONS DOSE AND ADMINISTRATION SIDE EFFECT AND PRECAUTIONS ADENOSINE • First drug for most form of stable narrow- complex PSVT • Give 6 mg adenosine as a rapid IV push followed by a 20mL saline flush. If unsuccessful, this can be followed with up to two doses each of 12mg every 1-2 minutes • Transient unpleasant side effects, in particular nausea, flushing, and chest discomfort • Caution if need to be given in asthmatic patient AMIODARONE • Refractory pulseless VT/VF ( persistent after at least 3 shock and adrenaline ) • Unstable tachyarrhythmias (failed3x cardioversion ) • Stable tachyarrhythmias • Refractory pulseless VT /VF ; IV/IO 300mg bolus (dilute in 20mL Dextrose 5% solution) Can repeat after the 5th shock :150 mg • Unstable tachyarrhythmias; 300mg IV over 10-20 minutes • Stable tachyarrhythmias; 300mg IV over 20-60 minutes • Maintenance infusion; 900 mg IV over 24h • hypotension, bradycardia and heart block
- 50. DRUGS IN RESUSCITATION DRUGINDICATIONS DOSE AND ADMINISTRATION SIDE EFFECT AND PRECAUTIONS CALCIUM Only in Pulseless Electrical Activity caused by • hyperkalaemia • hypocalcaemia • overdose of calcium channel blocker • The initial dose of 10 ml 10% calcium chloride (6.8 mmol Ca2+) may be repeated if necessary • Calcium can slow heart rate and precipitate arrhythmias • In cardiac arrest, calcium may be given by rapid intravenous injection LIGNOCAINE Alternative to amiodarone in cardiac arrest from VT/VF Stable monomorphic VT with preserved ventricular function Cardiac arrest from VT/VF Initial dose:1-1.5mg/kg IV or IO For refractory VF: may give additional dose 0.5- 0.75mg/kg and repeat 5- 10 minutes up to 3 times or maximal dose of 3mg/kg In overdose it can cause slurred speech, altered consciousness, muscle twitching and seizure It also can cause hypotension, bradycardia, heart block and asytoleAdvanced
- 51. DRUGS IN RESUSCITATION DRUGINDICATIONS DOSE AND ADMINISTRATION SIDE EFFECT AND PRECAUTIONS DOPAMINE • Second-line drug for symptomatic bradycardia • Use for hypotension • Usual infusion rate is 2- 20μg/kg/minute and dose titrated according to response • Can cause tachycardia, hypertension • Can precipitate arrhythmias MAGNESIUM • Torsades de pointes • Hypomagnesemia • Cardiac arrest due to Torsades de pointes or hypomagnesemia: 1-2g diluted in 10 mL D5% to be givenover 5-20 minutes • Torsades de pointes with pulse or AMI with hypomagnesemia: Loading dose of 1-2g mixed with 50 mLD5% over 5-60 minute, followed with 0.5 to 1g/hour (titrate to control Torsades) • Occasional fall in blood pressure with rapid administration
- 52. DRUGS IN RESUSCITATION DRUGINDICATIONS DOSE AND ADMINISTRATION SIDE EFFECT AND PRECAUTIONS VERAPAMIL • Used for narrow- complex paroxysymal SVT (unconverted by vagal maneuvers or adenosine ) • Arrhythmias known with certainty to be of supraventricular origin • 2.5– 5 mg IV over 2 min: repeated doses 5- 10 mg every 15-30 min to a maximum 20 mg • If given to patient with ventricular tachycardia may cause cardiovascular collapse SODIUM BICARBONATE • Known prexisting hyperkalemia • Known preexisting bicarbonate responsive acidosis e.g. : aspirin overdose, diabetic ketoacidosis, tricyclic antidepressant or cocaine • 1 mEq/kg IV bolus • May cause tissue necrosis if extravasation occurs • Do not administer together with IV line used for vasopressors or Calcium
- 53. DRUGS IN RESUSCITATION DRUGINDICATIONS DOSE AND ADMINISTRATION SIDE EFFECT AND PRECAUTIONS DOBUTAMINE • In hypotension with poor output state • With present of pulmonary oedema and hypotension prevents the use of other vasodilators • 5– 20 mcg/kg/min as continuous infusion • May worsen hypotension especially at the initial treatment. • Can increase risk of arrhythmia, including fatal arrhythmias NOREADRENALINE • Used for hypotension in post resuscitation period • Cardiogenic shock • 0.05– 1mcg/kg/min as continuous infusion • Cause tissue necrosis if extravasation occurs • Do not administer Sodium Bicarbonate • through the same IV line containing • Noradrenaline
- 54. TRANSCUTANEOUS PACING Explainand consent IV sedation and analgesia, oxygenation Attach self adhesive pacing pad Set pacing mode: FIXED MODE: deliver a fixed number of beats regardless of patient’s intrinsic heart rate DEMAND MODE: only deliver beats when patient’s heart rate falls below the heart rate Set heart rate about 60-70 beats/minute Set current output level to minimum setting Turn pacer ON Note presence of pacing spike Increase current slowly
- 55. Watch forelectrical capture: Pacing spikes followed by a broad QRS complex with T waves Check for mechanical capture: palpable pulse with broad QRS complex
- 56. DEFIBRILLATION VS SYNCHRONIZED CARDIOVERSION DEFIBRILLATION The passage of an electrical current across the myocardium to depolarise a critical mass of myocardium and enable restoration of coordinated electrical activity Aims to restore sinus rhythm Indicated only for VF or pulseless ventricular tachycardia (pVT) SYNCHRONIZED CARDIOVERSION Deliver shock at the peak of QRS complex (highest point of R wave) Deliver lower energy than defibrillation Can avoid delivery of shock during cardiac repolarization (T wave) which can precipitate VF. Remember: low-energy shock should always be delivered as synchronized shock to avoid precipitating VF
- 57. DEFIBRILLATION VS SYNCHRONIZED CARDIOVERSION DEFIBRILLATIONCARDIOVERSION Not synchronized Synchronized on the R wave For cardiac arrest For periarrest tachyarrythmias (unstable) Higher energy joules Lower energy joules No escalating energy for next shock Escalate energy for next shock (100 – 200 – 300 – 360J)
- 58. REFERENCES Advanced LifeSupport – Training Manual by MOH 2017 Guidelines for Resuscitation Training in Ministry of Health Malaysia Hospitals and Healthcare Facilities Tintinalli Emergency Medicine (8th edition 2015)
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