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- 1. ECG & PHARMACOLOGY This document is a property of FDM Training Center for Allied Health Professionals Inc., and the contents are treated confidential. Therefore, unauthorized reproduction is strictly prohibited unless otherwise permitted by the Management.
- 2. Filipinos Deserve More Anatomy of the Heart AO = Aorta LA = Left Atrium RA = Right Atrium RV = Right Ventricle LV = Left Ventricle RA LA RV LV AO PA = Pulmonary Artery PA
- 4. Filipinos Deserve More Anatomy of the ECG • P wave • PR interval • QRS complex • ST segment • T wave
- 5. Filipinos Deserve More Sinus Node 60-100 bpm Purkinje System 30-40 bpm or less AV Node (junctional cells) 40-60 bpm Failure of a pacemaker allows a subsidiary pacemaker to fire. His Bundle Pacemakers of the heart
- 6. Filipinos Deserve More Lines and Calibration } 1 small box = 0.04 sec }5 small boxes = 1 BIG box 0.20 sec What is the approximate PR Interval in this rhythm strip? }
- 7. Filipinos Deserve More • PR interval 0.12 ® 0.20 s • QRS complex <0.12 s ECG Measurements PREARREST
- 8. Filipinos Deserve More Heart Rate Estimation 1. Pick a complex that falls on a heavy line 2. Then estimate the rate by counting heavy boxes 3. Using 300, 150, 100, 75, 60, 50, 40, 30 75 to 100 bpm 300 150 100 75 60 50 40 30
- 9. Filipinos Deserve More 5 • Rate? • Normal • Bradycardia, Tachycardia • Rhythm? • Regular or Irregular • Are there P waves? • Is each P wave related to a QRS with 1:1 impulse conduction? • PR Interval? • Normal • Prolonged • QRS normal or wide? RHYTHM ANALYSIS Questions
- 10. Filipinos Deserve More • Disturbance in Automaticity • Pacemaker speeds up • New pacemaker takes over • Disturbance in Conduction • Slowing or block in conduction of electrical impulse • Combination of Both • Reentry arrhythmias
- 11. Filipinos Deserve More Normal Sinus Rhythm • Rate 60-100/min • Rhythm Regular • P waves Present • P → QRS 1:1 Conduction • PR Interval 0.16 seconds • QRS Complex Normal 300 150 100 75
- 12. Filipinos Deserve More • Rate <60/min • Rhythm Regular • P waves Present • P → QRS 1:1 Conduction • PR Interval 0.16 seconds • QRS Complex Normal Sinus Bradycardia 300 150 100 75 60 50 40 30
- 13. Filipinos Deserve More • Rate >100/min • Rhythm Regular • P waves Present • P → QRS 1:1 Conduction • PR Interval 0.16 seconds • QRS Complex Normal Sinus Tachycardia 300 150 100
- 14. Filipinos Deserve More Premature Atrial Contraction (PAC) ä • Rate Sinus Rate • Rhythm Irregular—interrupted by PAC Incomplete compensatory pause • P waves Different morphology • P → QRS 1:1 Conduction • PR Interval 0.16 seconds • QRS Complex Normal 300 150 100 75
- 15. Filipinos Deserve More Atrial Fibrillation * • Rate Atrial rate cannot be measured • Rhythm Ventricular rate—variable Irregular (irregularly irregular) • P waves Absent (fibrillation waves) • F → QRS Conduction irregular • PR Interval N/A • QRS Complex Normal
- 16. Filipinos Deserve More Atrial Flutter * • Rate Atrial rate 250-400/min (often 300) • Rhythm Ventricular rate—variable • P waves Absent (flutter waves) • F → QRS Conduction regular • PR Interval N/A • QRS Complex Normal
- 17. Filipinos Deserve More Reentry (Paroxysmal) SVT Usually onsets with PAC • Rate Atrial rate 150-250/min • Rhythm Onset tachycardia abrupt Regular • P waves Present—inverted in leads 2, 3, & aVF • P → QRS Conduction regular • PR Interval Normal • QRS Complex Narrow
- 18. Filipinos Deserve More Premature Ventricular Contraction (PVC) ä • Rate Sinus Rate • Rhythm Irregular—interrupted by PVC Complete compensatory pause • P waves Different morphology • P → QRS 1:1 Conduction • PR Interval 0.16 seconds • QRS Complex Normal
- 19. Filipinos Deserve More Ventricular Tachycardia Monomorphic* ä • Rate Tachycardia • Rhythm Onset tachycardia abrupt Regular • P waves Present - obscured • P → QRS Blocked - fusion complexes possible • PR Interval N/A • QRS Complex Wide
- 20. Filipinos Deserve More Polymorphic VT* • Rate Tachycardia • Rhythm Onset tachycardia abrupt Irregular • P waves Present – obscured • P → QRS Blocked - fusion complexes possible • PR Interval N/A • QRS Complex Wide
- 21. Filipinos Deserve More Ventricular Fibrillation * • Rate Chaotic, uncountable • Rhythm Irregular • P waves Absent • P → QRS N/A • PR Interval N/A • QRS Complex No normal QRS complexes
- 22. Filipinos Deserve More Asystole Agonal Complexes Pulseless Electrical Activity ASYSTOLE • Rate Absent • Rhythm None – flat line • P waves Absent • P → QRS N/A • PR Interval N/A • QRS Complex Absent
- 23. Filipinos Deserve More Pulseless Electrical Activity (PEA) • Rate Absent • Rhythm PEA is not a single rhythm but any organized rhythm without a pulse • P waves Present • P → QRS 1:1 Conduction • PR Interval Usually normal • QRS Complex Normal
- 24. Filipinos Deserve More Normal AV Conduction •Underlying sinus rhythm •One P wave •PR interval 0.12 to 0.20 seconds •One P wave for each QRS AV Nodal Tissue AV Node His-Purkinje System P QRS <0.12 0.12-0.20 seconds Sinus Node
- 25. Filipinos Deserve More Normal AV Conduction •Underlying sinus rhythm •One P wave •PR interval 0.12 to 0.20 seconds •One P wave for each QRS Prolongation –PR Interval more than 20 seconds Dropped Beat P-wave without QRS
- 26. Filipinos Deserve More •Atrioventricular Blocks •Classification •Complete AV Block Third-Degree AV Block •Incomplete AV Block First-Degree AV Block Second-Degree AV Block Type I—Wenckebach Mobitz I Type II—Mobitz II
- 27. Filipinos Deserve More First-Degree AV Block •Underlying sinus rhythm •One P wave •PR interval >0.20 second •One P wave for each QRS AV Nodal Tissue His-Purkinje System P QRS <0.12 >0.20 seconds Sinus Node
- 28. Filipinos Deserve More First-Degree AV Block DROPPED BEAT PROLONGATION PRoL PRoL PRoL 9 boxes 9 boxes 9 boxes
- 29. Filipinos Deserve More •Underlying sinus rhythm •P wave fails to periodically conduct •PR interval prolonged •One P wave for each QRS until block PR interval AV Nodal Tissue His-Purkinje System >0.20 seconds Sinus Node QRS X P Second-Degree AV Block - Mobitz I Wenckebach Phenomenon
- 30. Filipinos Deserve More Second-Degree AV Block - Mobitz I DROPPED BEAT PROLONGATION PRoL PRoL 8 11 PRoL 8 PRoL 11
- 31. Filipinos Deserve More • Underlying sinus rhythm • One P wave • PR interval usually normal, no prolongation • One P wave for each QRS until sudden block and dropped QRS Second-Degree AV Block -Mobitz II AV Nodal Tissue AV Node His-Purkinje System P Often normal QRS complex Often Normal Sinus Node Ò Block
- 32. Filipinos Deserve More Second-Degree AV Block -Mobitz II DROPPED BEAT PROLONGATION 11
- 33. Filipinos Deserve More • Underlying sinus rhythm (usual) • Escape junctional rate 40-60 • PR interval variable • P waves unrelated to QRS • Narrow QRS = block above His junction AV Node His Purkinje System P QRS <0.12 Sinus Node QRS from AV-His escape ã Ò Third-Degree AV Block—Junctional Escape P waves unrelated to QRS
- 34. Filipinos Deserve More • Underlying sinus rhythm (usual) • Escape junctional rate 40-60 • PR interval variable • P waves unrelated to QRS • Narrow QRS = block above His junction AV Node His Purkinje System P QRS <0.12 Sinus Node QRS from AV-His escape ã Ò Third-Degree AV Block—Junctional Escape P waves unrelated to QRS
- 35. Filipinos Deserve More • Underlying sinus rhythm (usual) • Escape ventricular rate 30-40 • PR interval variable • P waves unrelated to QRS • Wide QRS = block below His junction AV Node P Sinus Node His-Purkinje System QRS >0.12 QRS from His-Purkinje escape ã P waves unrelated to QRS Third-Degree AV Block—Ventricular Escape
- 36. Filipinos Deserve More summary AVB DROPPED BEAT PROLONGATION First Degree AVB Mobitz I Mobitz II Third Degree AVB ALTERNATES / VARIABLE
- 37. Filipinos Deserve More AV Block - Which Type? u v w x DROPPED BEAT PROLONGATION AVB Variable Third Degree First Degree Mobitz II Mobitz I
- 38. Filipinos Deserve More Thank you for choosing FDM Training Center for your Forward Learning! This document is a property of FDM Training Center for Allied Health Professionals Inc., and the contents are treated confidential. Therefore, unauthorized reproduction is strictly prohibited unless otherwise permitted by the Management. ECG & PHARMACOLOGY
- 39. ADVANCED CARDIOVASCULAR LIFE SUPPORT This document is a property of FDM Training Center for Allied Health Professionals Inc., and the contents are treated confidential. Therefore, unauthorized reproduction is strictly prohibited unless otherwise permitted by the Management.
- 40. Filipinos Deserve More PRE-ARREST ARREST POST-ARREST (ROSC) V VISUALIZE CONSCIOUSNESS, BREATHING, COLOR VERBALIZE SAMPLE VITAL SIGNS AIRWAY, BREATHING, CIRCULATION DISABILITY, EXPOSURE O M OXYGENATE if SpO2 95% Nasal Cannula 2-4 Face Mask 6-10 NRM 11-15 Monitor I Establish an IV/IO Access T A B RESCUE BREATHING: 1 q 6 sec ADVANCED AIRWAY: Primary confirmation: 5-pt auscultation Secondary confirmation: Qualitative - Yellow Quantitative - Waveform Capnography (35-45 mmHg) C 1-2L PNSS/PLRS Dopamine 5-10 mcg/kg/min Epinephrine 0.1 – 0.5 mcg/min Norepinephrine 0.1 – 0.5 mcg/kg/min D TARGETED TEMPERATURE MANAGEMENT 30 mL/kg PNSS/PLRS 4oC x 30mins Core body temp: 32-36 At least 24 hours NGT 12-LEAD CVP CXRAY URINARY CATHETER STEMI – CATH LAB NSTEMI - ICU E Parameters of HQCPR: • Push HARD: depth (2-2.4 in = 5-6 cm) • Push FAST: rate (100-120 comp/min) • Allow chest recoil • Minimize interruptions <10 sec • Avoid excessive ventilation TEAM DYNAMICS • Clear Roles and Responsibilities • Knowing your Limitation • Constructive Intervention • Knowledge Sharing • Summarizing and Re-evaluation • Mutual Respect • Clear Messages • Close-Loop Communication Assess CPR quality: Continuous Waveform Capnography (10mmHg)
- 41. Filipinos Deserve More MEGACODE PHASES Phase Patient is alive but may be experiencing a life-threatening problem. Status Goal Pre-Arrest Prevent Cardiac Arrest Patient has No Pulse, No Breathing and Unresponsive Cardiac Arrest Revive the patient and achieve Return Of Spontaneous Circulation (ROSC) Patient has achieved Return Of Spontaneous Circulation Post Arrest Stabilize the patient
- 42. Filipinos Deserve More SYSTEMATIC APPROACH V Visualize Initial Impression Consciousness Breathing Color Vital Signs Primary Assessment Airway Breathing Circulation Disability Exposure Ø Is the patient conscious? Ø Is the patient breathing? Ø Pallor / Cyanotic Ø RR and O2 Saturation Ø HR & BP Ø Assess AVPU Ø Trauma & Temperature Verbalize Secondary Assessment Signs & Symptoms Allergy Medications Past Medical Hx Last Meal Event Ø How are you feeling? Ø Do you have allergies with food/ meds? Ø Past Hospitalization / Familial Dse Ø What where you doing prior the s/sx? Ø Any maintenance meds? Ø What & when was your last meal? O M I T PRE ARREST Alert Voice Pain Unresponsive
- 43. Filipinos Deserve More PRE ARREST VO M I T Oxygen Monitor Intravenous Access If O2 saturation is >95%, provide supplemental O2. Nasal Cannula: 2-4 L/min Face Mask: 6-10 L/min Non-Rebreather:11-15 L/min Attach 3-lead ECG: WHITE – Right upper chest below the clavicle BLACK – Left upper chest below the clavicle RED – Left lower chest SALT PEPPER CHILI Peripheral antecubital vein of the non-dominant hand.` Ø Large Bore Ø Non-Collapsable 2 failed attempts: proceed to Intraosseous Access (IO) Ø Medial Malleolus Ø Proximal Tibia Ø Humeral Head Ø Sternum
- 44. Filipinos Deserve More PRE ARREST VO M I T Treatment Bradycardia Tachycardia ØSinus Bradycardia Ø1st Degree AV Block Ø2nd Degree AV Block (Mobitz 1) Ø2nd Degree AV Block (Mobitz 2) Ø3rd Degree AV Block ØSupraventricular Tachycardia ØMonomorphic Ventricular Tachycardia (+ pulse) Based in the Rhythmand Status of the Patient
- 45. Filipinos Deserve More Rhythm Stable Unstable Sinus Bradycardia MONITOR & OBSERVE A Atropine 1 mg bolus every 3-5 minutes Maximum dose: 3 mg First Degree AV BLOCK T Transcutaneous Pacing (TCP) 2ND DEGREE TYPE 1 (MOBITZ TYPE 1) D Dopamine 5-20 mcg/kg/min E Epinephrine 2-10 mcg/min 2ND DEGREE TYPE 2 (MOBITZ TYPE 2) TDE only 3RD DEGREE AV BLOCK Bradycardia Treatment
- 46. Filipinos Deserve More Tachycardia Treatment RHYTHM STABLE UNSTABLE SVT Supraventricu lar Tachycardia P Physiologic: VAGAL MANEUVERS 1. CSM for 5-10 seconds (No to 60y/o) 2. Cough forcefully 3x S Sedate: Propofol ; Etomidate ; Diazepam ; Midazolam Pharmacologic: ADENOSINE 6mg, 12mg, 12mg 1-2 mins interval Synchronized Cardioversion 50J Monomorphic Ventricular Tachycardia (+) Pulse P Physician S Sedate Pharmacologic: AMIODARONE 150mg infusion over 10 minutes Synchronized Cardioversion 100J
- 47. Filipinos Deserve More BLS SURVEY 1 RESCUER • Check scene safety “Scene is safe” • Check for responsiveness “Hey are you okay?” • Shout for help “Help! Someone Help! • Check for pulse & breathing for at least 5 no more than 10 sec. *No pulse, No Breathing • “Activate emergency response and get and AED.” • Start High Quality CPR. CODE BLUE Crash Cart CARDIAC ARREST
- 49. Filipinos Deserve More Delegating Team Roles Compressor “Push hard at a depth of 5-6 cm or 2-2.4 inches.” “Push fast at a rate of 100-120 compressions per minute.” ”Allow full chest recoil.” “Minimize interruptions to less than 10 seconds.” “Switch with the monitor every 2 minutes / you feel tired.” Airway “Give 2 breaths every 30 compressions.” “Make sure there is chest rise.” “Avoid excessive ventilation , give 1 breath over 1 second.” Monitor “Secure the pads and give shock as I order.” Medication “Secure the IV/IO and give meds as I order.” Recorder “Record the events of the code.” “Prompt me every 2 minutes.”
- 50. Filipinos Deserve More 15 seconds before 2 mins: • Pulse check with compressions: note if positive or negative pulse • Pre-charge the defibrillator 2 mins: • Hands hover over the chest • Pulse check without compressions • Analyze the rhythm • Deliver shock for shockable rhythm Ø Pads on the chest, shocking shock delivered • Switch Compressions every 2 mins or if tired CHEST HIGH PERFORMANCE TEAM(METRICS) Real time feedback device (metronome) Continue compressions during intubation (Non-COVID)
- 51. Filipinos Deserve More SHOCKABLE NON-SHOCKABLE Ventricular Fibrillation Asystole Pulseless Ventricular Tachycardia 1.Monomorphic 2.Polymorphic Pulseless Electrical Activity Cardiac Arrest Rhythms
- 52. Filipinos Deserve More Cardiac Arrest Management CLASS I CLASS IIA CLASS IIB High Quality CPR Shock : 360 Joules Medication Vfib Vtach Asystole PEA Epinephrine Amiodarone Ø1 mg, 1: 10,000 Dilution ØInterval of 3-5mins ØPriority Medication Ø2nd dose: 150 mg IV bolus Ø1st dose: 300 mg IV bolus Lidocaine Ø2nd dose: 0.5 – 0.75 mg/kg Ø1st dose: 1 – 1.5 mg/kg
- 53. Filipinos Deserve More TEAM DYNAMICS ROLES ü Clear Roles & Responsibilities ü Knowing your limitation ü Constructive intervention HOW TO COMMUNICATE WHAT TO COMMUNICATE ü Knowledge Sharing ü Summarizing & Re-evaluating üMutual Respect üClear Messages üClose-loop Communication
- 54. Filipinos Deserve More Airway Breathing Circulation Disability Endorsement Attach Contraptions No spontaneous breathing ADVANCED AIRWAY: Primary confirmation- 5-pt auscultation Secondary confirmation: Qualitative - yellow Quantitative – 35 to 40 mmHg PETCO2 Unstable BP • 1-2L PNSS/PLRS • Dopamine 5-10 mcg/kg/min • Epinephrine 0.1 – 0.5 mcg/kg/min • Norepinephrine 0.1 – 0.5 mcg/kg/min Comatose TARGETED TEMPERATURE MANAGEMENT • 30 mL/kg PNSS/PLRS 4oC • Core body temp: 32oC-36oC • At least 24 hours NGT 12-LEAD CVP CXRAY URINARY CATHETER Post Arrest Management Initial Stabilization Phase Continued Care
- 56. Filipinos Deserve More AIRWAY & BREATHING Check if the patient can breath on his own Positive pulse but NO breathing ADULT INFANT 1 breath every 6 seconds 1 breath every 2-3 seconds 10 breaths per minute 20-30 breaths per minute Note: Re-assess pulse every 2 minutes. If pulse is NOT present, proceed with CPR. NOT present CPR Perform Rescue Breathing Note: If No chest rise, proceed with MRSOPA
- 57. Filipinos Deserve More AIRWAY & BREATHING M ask adjustment R eposition the head and neck S uction secretions O pen the mouth P ressure increase A irway adjuncts: NPA OPA Ø Tip of the nose to the earlobe Ø Corner of the lips to the angle of mandible
- 58. Filipinos Deserve More AIRWAY & BREATHING Consider Advanced Airway Assessment of Endotracheal Tube placement Qualitative Ø 5 point Auscultation Ø Colorimetric Device Change from White to Yellow or from Purple to Yellow Quantitative Ø Continuous Waveform Capnography • Most Reliable • This measures the PETCO2 • Alive patient: 35 to 45 mmHg • Dead patient during CPR: 10 mmHg If you do not achieve 10 mmHg, it means your CPR is ineffective and needs to be improved.
- 59. Filipinos Deserve More CIRCULATION Blood Pressure: at least 90/60 mmHg NOT CONGESTED CONGESTED Fluid Replacement : 1-2 L or 30 mL/ kg of PNSS/PLR NO FLUID Medication • Dopamine: 5 – 10 mcg/kg/min • Epinephrine: 0.1 – 0.5 mcg/kg/min • Norepinephrine: 0.1 – 0.5 mcg/kg/min
- 60. Filipinos Deserve More DISABILITY Check for AVPU NOT CONGESTED CONGESTED Fluid Replacement at 4º Celsius : 1-2 L or 30 mL/ kg of PNSS/PLR NO FLUID External Measures: Cooling blankets, ice packs, lower room temperature If patient has GCS of 3/15 Start Targeted Temperature Management Target 32 – 36º Celsius for 24 hours Evaluate Ø Esophageal thermometer Ø Bladder thermometer
- 61. Filipinos Deserve More Other Critical Care Management
- 62. Filipinos Deserve More Nasogastric Tube Indwelling Foley Catheter 12 L ECG Gastric Decompression Rule out STEMI & continuous cardiac monitoring Check for rib fractures Monitor Central Venous Presuure Portable X-ray Central Venous Line Endorsement Attach Contraptions Output Monitoring Endorse to ICU; to the INTENSIVIST
- 64. Filipinos Deserve More ACUTE CORONARY SYNDROMES Initial Management •O – Oxygen •A – Aspirin 160 - 325 mg •N – Nitroglycerin 0.3 -0.4 mg •M – Morphine 2 – 4 mg
- 65. Filipinos Deserve More 1st 90 Minutes or less • Percutaneous Coronary Intervention (PCI) - Preferred treatment - First Medical Contact to Balloon inflation time • Sites: - Brachial - Radial - Femoral To perform PCI, a hospital should be equipped with a catheterization lab.
- 66. Filipinos Deserve More 1 2 3 4 5 6 7 8 Detection Dispatch Delivery Door Data Decision Drug Disposition STROKE CARE 8DS Best practice for suspected stroke is to bypass the emergency department and go straight to the brain imaging suite per protocol.
- 68. Filipinos Deserve More Thank you for choosing FDM Training Center for your Forward Learning! This document is a property of FDM Training Center for Allied Health Professionals Inc., and the contents are treated confidential. Therefore, unauthorized reproduction is strictly prohibited unless otherwise permitted by the Management. ADVANCED CARDIOVASCULAR LIFE SUPPORT