Presentation e acls aremt

Advanced Cardiac Life SupportAdvanced Cardiac Life SupportCraig StevensCraig Stevens

AREMT Instructor/ExaminerAREMT Instructor/ExaminerBachelor of Health Science ParamedicBachelor of Health Science Paramedic

Australasian Emergency ResponseAustralasian Emergency ResponseSpecialists Specialists Pty LtdPty Ltd

TASMANIA & PNG

A.E.R.SA.E.R.S Emergency Response & Specialist Training Services

Version 1 June 2009

Scope of TrainingScope of Training

•• The ACLS course provides participants the The ACLS course provides participants the opportunity to learn and review the following key opportunity to learn and review the following key components of advanced cardiac care:components of advanced cardiac care:–– ArrhythmiasArrhythmias–– Pharmacological therapyPharmacological therapy–– Electrical therapyElectrical therapy–– Patient assessment and managementPatient assessment and management

CertificationCertification

A wallet size reference card and A4 certificates will be issued on successful completion of this course.

Valid for 2 years and then can be refreshed/recertified over a half –1 day session after that.

IntroductionIntroduction

-- Welcome!Welcome!

-- The course you are about to participate in will be The course you are about to participate in will be conducted over 2 daysconducted over 2 days-- Day 1 Theory and Practical RehearsalsDay 1 Theory and Practical Rehearsals-- Day 2 Practical Stations & ExaminationDay 2 Practical Stations & Examination

-- Internationally recognised certification, with credits for Internationally recognised certification, with credits for doctors and nurses in continuing education.doctors and nurses in continuing education.

CasesCases-- There are 10 cases studied and the morphology There are 10 cases studied and the morphology

and management of these cases are covered in and management of these cases are covered in depth.depth.-- Acute Coronary SystemsAcute Coronary Systems-- AsystoleAsystole-- AEDAED-- BradycardiaBradycardia-- PEAPEA-- Narrow Complex tachycardiaNarrow Complex tachycardia-- Respiratory ArrestRespiratory Arrest-- StrokeStroke-- Ventricular FibrillationVentricular Fibrillation-- Wide Complex TachycardiaWide Complex Tachycardia

Conduct of CourseConduct of Course•• Review of Cardiac Rhythms Review of Cardiac Rhythms •• Pharmacologic and Electrical TherapyPharmacologic and Electrical Therapy•• Patient Assessment and the Cardiac PatientPatient Assessment and the Cardiac Patient•• Skills Practice and RemediationSkills Practice and Remediation•• ACLS Practice CasesACLS Practice Cases•• ACLS Practice Written Test and RemediationACLS Practice Written Test and Remediation•• Final Skills ExaminationFinal Skills Examination•• Final Written ExaminationFinal Written Examination

Any QuestionsAny Questions??

Chapter 1 Chapter 1 –– Review Cardiac Review Cardiac RhythmsRhythms

Cardiac Electrical Conduction Cardiac Electrical Conduction SystemSystemRevision:Revision:

Cardiac Electrical Conduction Cardiac Electrical Conduction SystemSystemAs you recall the myocardium is different from every other muscle.

It has an ability to produce it’s own electrical activity by a process call “automaticity”

Specialised conduction system with impulses generated by pace maker

The collection of nerve fibres sets the

inherent rate of electrical discharge

Cardiac Electrical Conduction Cardiac Electrical Conduction SystemSystem

Primary pacemaker is the “SA” Sino Atrial Node

““SASA”” SinoSino--Atrial NodeAtrial Node

Located in superior aspect of right atrium and discharges at 60 – 100beats per minute

Once initiated the SA node, impulse travels through right and left atria

Atria depolarises cells, the discharge stimulates atria muscle to contract


Impulse travels from “SA” Node to the “AV”(Atrio-Ventricular Node)

Located in wall of right atrium

The impulse from the “AV” Node is delayed slightly, before entering ventricles

““AVAV”” AtrioAtrio--Ventricular NodeVentricular Node

This allows the Atria and ventricles to beat independently whichprovides a double action pump

“AV” Node discharges at a rate of 40 – 60 impulses per minute


Accommodates the “right and left bundle branches”, terminating at the “Purkinje Network”

“Bundle of His” is located partially in the walls of the right atrium and inter-ventricular septum

““Bundle of HisBundle of His”” andand““Purkinje SystemPurkinje System””

The cells depolarise and cause the ventricles to contract at the“Purkinje” level

“Purkinje Network” discharges at a rate of 20 – 40 beats per minute


If the “AV” Node fails to capture the “Bundle of His” and “Purkinje Network”will take over with a considerable lower rate of contractility

If the “SA” Node is to fail the “AV”Node picks up the pace requirement, which fires at a delayed rate.

Conduction FailureConduction Failure

In both cases we see marked “Brady-cardia”


ECG WaveformsECG WaveformsEach event in the cardiac conduction system, produces a Each event in the cardiac conduction system, produces a

specific waveform that can be analysed on the ECG.specific waveform that can be analysed on the ECG.

ECG WaveformsECG Waveforms““PP”” wave is normally wave is normally

upright, first waveform, upright, first waveform, simultaneous simultaneous depolarisation of the depolarisation of the atriaatria

““PP--RR”” segment is the time segment is the time from from ““PP”” wave to wave to commencement of commencement of ““QRSQRS”” complex, which complex, which represents the delay in represents the delay in the the ““AVAV”” nodenode

TheThe ““PRPR”” interval is from commencement ofinterval is from commencement of ““PP”” wave to end ofwave to end of ““QRSQRS””represents the entire depolarisation of the atria and the delay represents the entire depolarisation of the atria and the delay of theof the““AVAV”” nodenode

Collectively the Collectively the ““QRSQRS”” segment is the entire depolarisation of the segment is the entire depolarisation of the ventriclesventricles

ECG WaveformsECG Waveforms

TheThe ““QQ”” wave is the first wave is the first negative deflection negative deflection after theafter the ““PP”” wave, wave, may or may not be may or may not be presentpresent

The The ““RR”” wave is the first wave is the first positive deflection after positive deflection after thethe ““PP”” wavewave

The The ““SS”” wave is the first negative deflection after the wave is the first negative deflection after the ““RR”” wavewave

ECG WaveformsECG WaveformsThe The ““SS--TT”” segment segment

represents time represents time between ventricular between ventricular depolarisation and depolarisation and repolarisationrepolarisation

Should be Should be ““IsoIso--electricelectric””(Neutral, baseline for (Neutral, baseline for ECG)ECG)

The The ““TT”” wave represents repolarisation of the ventricles, (ready to firwave represents repolarisation of the ventricles, (ready to fire)e)

Normal Sinus RhythmNormal Sinus RhythmWeWe’’ve look at the ECG representation, now letve look at the ECG representation, now let’’s look at s look at

the the ““Sinus RhythmSinus Rhythm””

Normal Sinus RhythmNormal Sinus RhythmWeWe’’ve look at the ECG representation, now letve look at the ECG representation, now let’’s look at s look at

the the ““Sinus RhythmSinus Rhythm””

Normal Sinus RhythmNormal Sinus Rhythm

The The ““Sinus RhythmSinus Rhythm”” indicates the indicates the ““SASA”” node is the primary node is the primary pacemaker site and all components are intact and functioning pacemaker site and all components are intact and functioning correctly.correctly.

ECG Markers of Acute Coronary ECG Markers of Acute Coronary SyndromeSyndromeThe The ““STST”” segment represents depolarisation and segment represents depolarisation and

repolarisation, it should be repolarisation, it should be ““IsoelectricIsoelectric””. .

Which identifies that the myocardium is electrically Which identifies that the myocardium is electrically ““NeutralNeutral””

ECG Markers of Acute Coronary ECG Markers of Acute Coronary Syndrome (ACS)Syndrome (ACS)

The The ““STST”” segment segment ““depressiondepression”” is commonly indicative of is commonly indicative of ““Myocardial IschemiaMyocardial Ischemia””

The The ““STST”” segment segment ““elevationelevation”” is commonly indicative of is commonly indicative of ““Myocardial Myocardial InjuryInjury””

These observations are only conclusive when seen in These observations are only conclusive when seen in 2 2 or more or more leads, therefore leads, therefore ““MCLMCL’’ss”” or a or a 12 lead12 lead needs to be used to needs to be used to confirm.confirm.

““TT”” Wave InversionWave Inversion

The The ““TT”” wave represents the wave represents the repolarisation of the ventricles.repolarisation of the ventricles.

Should be in the Should be in the same directionsame directionas the as the ““QRSQRS”” segment.segment.

Again these need to be observed Again these need to be observed in in 2 or more2 or more leads to be leads to be conclusiveconclusive

Those patients however presenting with signs and symptoms of Those patients however presenting with signs and symptoms of ““ACSACS””is clinically significant and to be treated as such until provenis clinically significant and to be treated as such until provenotherwise.otherwise.

The The ““QQ”” WaveWaveThe The ““QQ”” wave is the first negative deflection after the wave is the first negative deflection after the ““PP”” wave.wave.

““QQ”” waves are insignificant in some leads, this is not a safe waves are insignificant in some leads, this is not a safe assumption however in someone presenting with chest pain, and assumption however in someone presenting with chest pain, and showing them in showing them in multiple leadsmultiple leads on a 12 lead ECG.on a 12 lead ECG.

A significant pathologic A significant pathologic ““QQ”” wave is one that is seen to be deeper wave is one that is seen to be deeper than than 1/31/3 of the of the ““QRSQRS”” height or wider than height or wider than 0.030.03 secsec’’ss

The The ““QQ”” WaveWavePathologic Pathologic ““QQ”” waves represent waves represent ““dead myocardiumdead myocardium”” and and

are the ECG signature of a are the ECG signature of a ““Myocardial InfarctionMyocardial Infarction””..


BradycardiaBradycardia

Bradycardia is defined, Bradycardia is defined, ““by a heart rate of less than 60 beats per by a heart rate of less than 60 beats per minuteminute””..

Can result in a decreased cardiac output, which would make the Can result in a decreased cardiac output, which would make the patient clinically unstable.patient clinically unstable.

““AbsoluteAbsolute”” bradycardia refers to any heart rate bradycardia refers to any heart rate less than 60 beatsless than 60 beats per per minuteminute

““RelativeRelative”” bradycardia is when the bradycardia is when the heart rate is faster than expectedheart rate is faster than expected, , (May be >60 bpm) and is accompanied by (May be >60 bpm) and is accompanied by serious signs and serious signs and symptoms.symptoms.

EgEg: : Hypotension, Hypotension, or or Altered Mental StatusAltered Mental Status

Sinus BradycardiaSinus Bradycardia

Sinus BradycardiaSinus Bradycardia

““Sinus BradycardiaSinus Bradycardia”” Results from Results from ““excess vagal stimulationexcess vagal stimulation””,,which which slows slows ““SASA”” node dischargenode discharge

Other causes include:Other causes include:

-- DiseaseDisease

-- Damage to cardiac electrical conduction systemDamage to cardiac electrical conduction system

-- Certain drugs (Beta Certain drugs (Beta –– blockers)blockers)

******In well conditioned athletes sinus bradycardia may be present In well conditioned athletes sinus bradycardia may be present and a normal finding.and a normal finding.

IdioventricularIdioventricular RhythmRhythmIdioventricularIdioventricular RhythmRhythm occurs when a occurs when a ““ventricular ventricular focusfocus”” acts as the primary pacemaker of the heartacts as the primary pacemaker of the heart

IdioventricularIdioventricular RhythmRhythm

Origin:Origin:

This is evident by the This is evident by the wide and bizarrewide and bizarre appearance of the appearance of the ““QRSQRS”” complexes, complexes, and and slow ventricular rate.slow ventricular rate.

Because Because atrial activity is absentatrial activity is absent there are there are no discernable no discernable ““PP”” waves.waves.

Clinical Significance:Clinical Significance:

In an absence of atrial contraction, minimal volumes of blood arIn an absence of atrial contraction, minimal volumes of blood are ejected, into e ejected, into ventricles.ventricles.

Ventricular rate is slow, cardiac output significantly reduced. Ventricular rate is slow, cardiac output significantly reduced.

Heart BlocksHeart Blocks

““First Degree AV BlockFirst Degree AV Block””

Origin:Origin:

““First Degree AVFirst Degree AV”” block is caused by an abnormal delay at the AV node which block is caused by an abnormal delay at the AV node which prolongs the prolongs the ““PP--RR”” interval interval > 0.20 sec> 0.20 sec

What can cause this cardiac rhythm:What can cause this cardiac rhythm:

-- Vagal stimulationVagal stimulation

-- AV Nodal diseaseAV Nodal disease

-- Certain medicationsCertain medications


““First Degree AV BlockFirst Degree AV Block””


Unlike higher blocks, 1Unlike higher blocks, 1stst degree AV block is less likely to be associated degree AV block is less likely to be associated with Bradycardiawith Bradycardia

However if Bradycardia is present cardiac output can fallHowever if Bradycardia is present cardiac output can fall

11stst degree AV block can be a variant in some peopledegree AV block can be a variant in some people


““Second Degree AV Block Type 1Second Degree AV Block Type 1””

Origin:Origin:

22ndnd degree AV block Type I is caused by degree AV block Type I is caused by ““AVAV”” nodal disease or vagal nodal disease or vagal stimulation.stimulation.

Each complex progressively delayed at AV node until a Each complex progressively delayed at AV node until a ““QRSQRS”” segment segment is lost, leaving sole is lost, leaving sole ““PP”” wave with no associated QRS segment.wave with no associated QRS segment.


““Second Degree AV Block Type ISecond Degree AV Block Type I””


Depends on AV block (2:1, 3:1, 4:1 etc) this rhythm can either pDepends on AV block (2:1, 3:1, 4:1 etc) this rhythm can either present resent as a as a ““normalnormal”” or or ““bradycardicbradycardic”” rate.rate.

If associated with Bradycardia, cardiac output may decrease.If associated with Bradycardia, cardiac output may decrease.


““Second Degree AV Block Type IISecond Degree AV Block Type II””

Origin:Origin:

22ndnd degree AV Block Type II occurs when the degree AV Block Type II occurs when the AVAV node intermittently node intermittently blocks some atrial complexes.blocks some atrial complexes.

Results in some Results in some ““PP”” waves not followed by any waves not followed by any ““QRSQRS”” complexes.complexes.


““Second Degree AV Block Type IISecond Degree AV Block Type II””


22NDND Degree AV Block Type II results from more severe AV nodal Degree AV Block Type II results from more severe AV nodal disease, excessive vagal tonedisease, excessive vagal tone

Frequently associated with bradycardia and can decrease cardiac Frequently associated with bradycardia and can decrease cardiac outputoutput


““Third Degree AV BlockThird Degree AV Block””Origin:Origin:Occurs as a result of Occurs as a result of complete blockcomplete block at the at the ““AVAV”” node.node.

Complete blockage at AV node, prevents any atrial conducted Complete blockage at AV node, prevents any atrial conducted complexes to enter the ventriclescomplexes to enter the ventricles

Ventricles respond with escape complexes producing wide Ventricles respond with escape complexes producing wide ““QRSQRS””complex.complex.

Also referred to as Also referred to as ““CHB or Complete Heart BlockCHB or Complete Heart Block””


““Third Degree AV BlockThird Degree AV Block””Clinical Significance:Clinical Significance:

Atrial and Ventricle contractions are dissociated Atrial and Ventricle contractions are dissociated cardiac output is cardiac output is significantly decreasedsignificantly decreased and patient most always unstable.and patient most always unstable.

A ventricular pacemaker occurs at an intrinsic rate of A ventricular pacemaker occurs at an intrinsic rate of 20 20 –– 40 bpm40 bpmwith with wide wide ““QRSQRS”” complexes and complexes and severe bradycardiasevere bradycardia


TachycardiaTachycardia’’ss

-- Tachycardia Tachycardia is defined as,is defined as,”” heart rate that is > heart rate that is > 100bpm100bpm””..

-- Varying types, Varying types, narrow or broad complexnarrow or broad complex tachycardiatachycardia’’s s occur.occur.

-- If heart beats too fast, ventricles may not adequately fill.If heart beats too fast, ventricles may not adequately fill.

-- Decreases cardiac output, making clinically unstable Decreases cardiac output, making clinically unstable patient.patient.

TachycardiaTachycardia’’ssNarrow QRS ComplexNarrow QRS Complex

Sinus TachycardiaSinus TachycardiaOrigin:Origin:Sinus TachycardiaSinus Tachycardia occurs when the occurs when the SA SA node discharges faster than itnode discharges faster than it’’s s

inherent rate of inherent rate of 60 60 –– 100100 impulses per minute.impulses per minute.

This caused by, medication or required increased cardiac input. This caused by, medication or required increased cardiac input. (Shock, fever, hypoxemia, exercise)(Shock, fever, hypoxemia, exercise)

TachycardiaTachycardia’’s (Narrow Complex)s (Narrow Complex)Narrow QRS ComplexNarrow QRS Complex

Sinus TachycardiaSinus Tachycardia

Clinical Significance:Clinical Significance:Can result in a Can result in a decreased cardiacdecreased cardiac output secondary to output secondary to inadequate inadequate

ventricular filling.ventricular filling.

TachycardiaTachycardia’’s (Narrow Complex)s (Narrow Complex)

Supra Ventricular Tachycardia (SVT)Supra Ventricular Tachycardia (SVT)SVT can manifest as:SVT can manifest as:-- Atrial tachycardiaAtrial tachycardia-- Ectopic atrial tachycardiaEctopic atrial tachycardia-- Rapid atrial fibrillation or flutterRapid atrial fibrillation or flutter-- Junctional tachycardiaJunctional tachycardiaDefined as narrow complex tachycardiaDefined as narrow complex tachycardia exceeds >150 bpmexceeds >150 bpm


Supra Ventricular Tachycardia (SVT)Supra Ventricular Tachycardia (SVT)Origin:Origin:Occurs when a Occurs when a supraventricular pacemakersupraventricular pacemaker initiates the impulse. initiates the impulse. Not Not

necessarily the SA nodenecessarily the SA nodeSVTSVT can be caused by medications or situations requiring increased can be caused by medications or situations requiring increased

cardiac output.cardiac output.(Shock, fever, hypoxemia, exercise or SA node disease).(Shock, fever, hypoxemia, exercise or SA node disease).


Supra Ventricular Tachycardia (SVT)Supra Ventricular Tachycardia (SVT)

Clinical Significance:Clinical Significance:SVTSVT can result in a can result in a decreased cardiac outputdecreased cardiac output, secondary to , secondary to inadequate inadequate

ventricular filling, ventricular filling, More than sinus tachycardiaMore than sinus tachycardia


Atrial Fibrillation (AF)Atrial Fibrillation (AF)Origin:Origin:Result of Result of multiple atrial pacemakers discharging chaoticallymultiple atrial pacemakers discharging chaotically..

No discernible No discernible ““PP”” waves, only fibrillatory waves between waves, only fibrillatory waves between ““QRSQRS””

No electrical pattern from Atria causes No electrical pattern from Atria causes ““irregularly irregularirregularly irregular””ventricular rhythm, from the ventricular rhythm, from the AVAV node areanode area


Atrial Fibrillation (AF)Atrial Fibrillation (AF)Clinical Significance:Clinical Significance:Frequently in patients with Frequently in patients with ““Congestive Heart FailureCongestive Heart Failure”” (CHF)(CHF)

Tendency to have blood stagnate, causing potential for, Tendency to have blood stagnate, causing potential for, pulmonary, pulmonary, coronary or cerebral embolism.coronary or cerebral embolism.

When When >100bpm>100bpm, cardiac output decreases, which is compounded by , cardiac output decreases, which is compounded by decreased atrial kick from small volumes of blood delivered to decreased atrial kick from small volumes of blood delivered to ventriclesventricles


Atrial FlutterAtrial FlutterOrigin:Origin:Result of ectopic atrial pacemaker outside Result of ectopic atrial pacemaker outside SASA nodenode

Commonly lower atrium, near Commonly lower atrium, near AVAV nodenode

SA SA node function suppressed by flutternode function suppressed by flutter

““PP”” waves present as waves present as ““flutterflutter”” waves, as abnormal atrial depolarisation waves, as abnormal atrial depolarisation occurs near occurs near AVAV node across atria in a retrograde directionnode across atria in a retrograde direction


Atrial FlutterAtrial FlutterClinical Significance:Clinical Significance:Occurs in Occurs in ““CHFCHF”” and in those with and in those with SA node diseaseSA node disease

Complications occur with Complications occur with inadequate ventricular fillinginadequate ventricular filling especially when especially when accompanied by accompanied by rapid ventricular raterapid ventricular rate

Cardiac output Cardiac output significantly decreasedsignificantly decreased

TachycardiaTachycardia’’s (Wide Complex)s (Wide Complex)

Monomorphic Ventricular Tachycardia (VT)Monomorphic Ventricular Tachycardia (VT)Origin:Origin:Most common form ofMost common form of ““VTVT””

Complexes are allComplexes are all same shape, size and directionsame shape, size and direction

Caused byCaused by ectopic pacemaker in ventricle, ectopic pacemaker in ventricle, overrides atrial activityoverrides atrial activity

““PP”” waves waves may be seenmay be seen but but usually buriedusually buried in widein wide ““QRSQRS”” complexescomplexes


Monomorphic Ventricular Tachycardia (VT)Monomorphic Ventricular Tachycardia (VT)Clinical Significance:Clinical Significance:

Can result from many underlying causesCan result from many underlying causesMost commonly significant:Most commonly significant:-- ““Coronary Artery DiseaseCoronary Artery Disease””-- ““QTQT”” interval prolongationinterval prolongation-- Electrolyte imbalance, specifically potassium (K+)Electrolyte imbalance, specifically potassium (K+)


Polymorphic Ventricular Tachycardia (VT)Polymorphic Ventricular Tachycardia (VT)Origin:Origin:Complexes vary in Complexes vary in size, shape and directionsize, shape and direction from complex to complexfrom complex to complex

Usually occurs when Usually occurs when ““QTQT”” interval of underlying rhythm prolongsinterval of underlying rhythm prolongs, , indicating indicating severe delay in ventricular repolarisationsevere delay in ventricular repolarisation

Ventricles become irritated and ectopic ventricular pacemaker ovVentricles become irritated and ectopic ventricular pacemaker overrideserrides

Variant known as Variant known as ““TdPTdP”” -- ““Torsades De PointesTorsades De Pointes”” or or ““Twisting of PointsTwisting of Points””


Polymorphic Ventricular Tachycardia (VT)Polymorphic Ventricular Tachycardia (VT)Clinical Significance:Clinical Significance:Prone to occur after administration of Prone to occur after administration of ““QuinidineQuinidine”” or or ““ProcainamideProcainamide””

both drugs prolong the both drugs prolong the ““QTQT”” intervalintervalHypomagnesaemiaHypomagnesaemia (Low Magnesium) is also common cause(Low Magnesium) is also common causeAtria Atria do not contract regularly or adequatelydo not contract regularly or adequately to fill ventricles before to fill ventricles before

they contractthey contractMarked Marked reduction in cardiac outputreduction in cardiac outputHigh potential to deteriorate to High potential to deteriorate to ““Ventricular FibrillationVentricular Fibrillation””

Cardiac Arrest RhythmsCardiac Arrest Rhythms

Ventricular Fibrillation (VF)/ Pulseless Ventricular Ventricular Fibrillation (VF)/ Pulseless Ventricular TachycardiaTachycardia

Origin:Origin:Multiple ectopic ventricular pacemakers, which depolarise in a rMultiple ectopic ventricular pacemakers, which depolarise in a random, andom,

chaotic fashion and spread throughout myocardiumchaotic fashion and spread throughout myocardiumLethal arrhythmiaLethal arrhythmiaUncontrolled quiveringUncontrolled quivering



Clinical Significance:Clinical Significance:Does not produce a palpable pulseDoes not produce a palpable pulseMost common rhythm in cardiac arrestMost common rhythm in cardiac arrestImmediate defibrillation is criticalImmediate defibrillation is criticalCoronary Artery Disease, leads to myocardial ischemia/infarctionCoronary Artery Disease, leads to myocardial ischemia/infarction most most

common causecommon cause(Hypoxia, acidosis, early repolarisation, (Hypoxia, acidosis, early repolarisation, EgEg: : ““R on TR on T”” phenomenon)phenomenon)



Note:Note:““VTVT”” covered earlier can be with cardiac output or pulselesscovered earlier can be with cardiac output or pulseless

It can occur in patients in cardiac arrestIt can occur in patients in cardiac arrest

Not as common as Not as common as ““VFVF””,, but in witnessed arrest may be present before but in witnessed arrest may be present before ““VFVF””


AsystoleAsystoleOrigin:Origin:All pacemaker sites fail to generate electrical impulseAll pacemaker sites fail to generate electrical impulseTotal absence of electrical and mechanical activityTotal absence of electrical and mechanical activity

Clinical Significance:Clinical Significance:Asystole does not produce a pulse, Asystole does not produce a pulse, It is commonly the result of untreated ventricular fibrillation It is commonly the result of untreated ventricular fibrillation (VF)(VF)((EgEg: Hypoxia, acidosis or electrolyte abnormalities): Hypoxia, acidosis or electrolyte abnormalities)

Cardiac Arrest RhythmsCardiac Arrest RhythmsPulseless Electrical Activity (PEA)Pulseless Electrical Activity (PEA)

““PEAPEA”” is not a particular cardiac rhythm, but rather any cardiac is not a particular cardiac rhythm, but rather any cardiac arrhythmia that arrhythmia that does not produce a palpable pulse.does not produce a palpable pulse.

The only rhythm that is not classed as The only rhythm that is not classed as ““PEAPEA”” is is ““Pulseless VTPulseless VT””Can be caused by:Can be caused by:-- HypoxiaHypoxia-- AcidosisAcidosis-- Pericardial tamponadePericardial tamponade-- Tension pneumothorax/haemothoraxTension pneumothorax/haemothorax-- HypolvolaemiaHypolvolaemia

SummarySummaryIt is important to evaluate a cardiac rhythm of a patient with aIt is important to evaluate a cardiac rhythm of a patient with a cardiaccardiac--

related chief complaint.related chief complaint.

Evaluation of the ECG of the patients signs and symptoms determiEvaluation of the ECG of the patients signs and symptoms determines nes the most appropriate treatment protocols.the most appropriate treatment protocols.

More than one cardiac rhythm can be observed in a patient. The More than one cardiac rhythm can be observed in a patient. The clinician needs to be versatile enough to change the course of clinician needs to be versatile enough to change the course of management very quickly.management very quickly.

It is important to analyse and interpret, however a systemic assIt is important to analyse and interpret, however a systemic assessment essment is crucial in determining whether the cardiac rhythm is resultinis crucial in determining whether the cardiac rhythm is resulting in g in haemodynamic compromise.haemodynamic compromise.


Pharmacologic and Electrical Pharmacologic and Electrical TherapyTherapyIntroductionIntroductionThis chapter reviews the most common pharmacologic and electricaThis chapter reviews the most common pharmacologic and electrical l

interventions used in ACLS to treat patients with a variety of interventions used in ACLS to treat patients with a variety of cardiovascular and respiratory system emergencies.cardiovascular and respiratory system emergencies.

Pharmacologic and Electrical Pharmacologic and Electrical TherapyTherapyAcute Coronary Syndrome Acute Coronary Syndrome –– PharmacologyPharmacology

Aspirin (Acetylsalicylic Acid, ASA)Aspirin (Acetylsalicylic Acid, ASA)Therapeutic EffectsTherapeutic Effects-- Blocks formation of thromboxane A2, Blocks formation of thromboxane A2, -- Inhibiting platelet aggregation and vasoconstrictionInhibiting platelet aggregation and vasoconstriction-- Reduces mortality from acute myocardial infarction, reduces Reduces mortality from acute myocardial infarction, reduces

reinfarction and nonfatal strokereinfarction and nonfatal strokeIndicationsIndications-- S & S suggestive of ACS such as chest pain or discomfortS & S suggestive of ACS such as chest pain or discomfort-- ECG changes consistent with ACS,ECG changes consistent with ACS,

-- ST Depression/ElevationST Depression/Elevation-- T wave inversionT wave inversion


Aspirin (Acetylsalicylic Acid, ASA)Aspirin (Acetylsalicylic Acid, ASA)ContraContra--IndicationsIndications-- Known hypersensitivityKnown hypersensitivity-- Bleeding disordersBleeding disorders-- Concomitant use of antiConcomitant use of anti--coagulantscoagulants-- Active ulcer, or recent GI BleedActive ulcer, or recent GI BleedAdult DoseAdult Dose-- 160 160 –– 325mg325mg of chewable aspirin of chewable aspirin ASAPASAP after after onset of chest painonset of chest pain-- To achieve peak therapeutic plasma levels, instruct patient to To achieve peak therapeutic plasma levels, instruct patient to chew chew

tablet before swallowingtablet before swallowing


Fibrinolytic Therapy (Thrombolytics)Fibrinolytic Therapy (Thrombolytics)Therapeutic EffectsTherapeutic Effects-- Alteplase (Activase, tPA), Anistreplase (Eminase), Reteplase Alteplase (Activase, tPA), Anistreplase (Eminase), Reteplase

(Retavase), Streptekinase, Tenectaplase(Retavase), Streptekinase, Tenectaplase

-- Produce similar therapeutic effect, which is the conversion of Produce similar therapeutic effect, which is the conversion of plasminogen to plasmin.plasminogen to plasmin.

-- Plasmin destroys fibrin and fibrinogen matrix of thrombus, destrPlasmin destroys fibrin and fibrinogen matrix of thrombus, destroying oying clot obstructing the artery and reclot obstructing the artery and re--establishing distal blood flow establishing distal blood flow


Fibrinolytic Therapy (Thrombolytics)Fibrinolytic Therapy (Thrombolytics)Indications:Indications:-- Acute Myocardial Infarction (AMI) in adultsAcute Myocardial Infarction (AMI) in adults

-- ST segment elevation > or equal to 1mm in 2 or more contiguous lST segment elevation > or equal to 1mm in 2 or more contiguous leadseads-- In S & S of AMI, no > than 12 hours from duration of onset (chesIn S & S of AMI, no > than 12 hours from duration of onset (chest pain)t pain)

-- Acute Ischaemic StrokeAcute Ischaemic Stroke-- Sudden onset focal neurologic deficit (slurred speech, facial drSudden onset focal neurologic deficit (slurred speech, facial droop) or oop) or

alterations in mental status alterations in mental status -- Absence of intracerebral/subarachnoid haemorrhage (rule out if Absence of intracerebral/subarachnoid haemorrhage (rule out if

required)required)-- S & S not rapidly improving (TIA)S & S not rapidly improving (TIA)-- S & S no > 3 hours in durationS & S no > 3 hours in duration

Pharmacologic and Electrical Pharmacologic and Electrical TherapyTherapyAcute Coronary Syndrome Acute Coronary Syndrome –– PharmacologyPharmacologyFibrinolytic Therapy (Thrombolytics)Fibrinolytic Therapy (Thrombolytics)ContraContra--Indications:Indications:-- Active bleeding within 21 days, menses excludedActive bleeding within 21 days, menses excluded-- History of intraHistory of intra--cerebral, intracranial, or intracerebral, intracranial, or intra--spinal event within 3 spinal event within 3

monthsmonths-- StrokeStroke-- Arteriovenous (AV) malformationArteriovenous (AV) malformation-- NeoplasmNeoplasm-- AneurismAneurism-- Trauma or surgeryTrauma or surgery-- Major trauma or surgery in last 14 daysMajor trauma or surgery in last 14 days-- Aortic dissectionAortic dissection-- Severe uncontrolled hypertensionSevere uncontrolled hypertension-- Severe bleeding disordersSevere bleeding disorders


Fibrinolytic Therapy (Thrombolytics)Fibrinolytic Therapy (Thrombolytics)ContraContra--Indications:Indications:-- History of intraHistory of intra--cerebral, intracranial, or intracerebral, intracranial, or intra--spinal event within 3 spinal event within 3

months contmonths cont……....-- History of prolonged CPR with evidence of thoracic traumaHistory of prolonged CPR with evidence of thoracic trauma-- Lumbar puncture within 7 daysLumbar puncture within 7 days-- Recent arterial puncture or nonRecent arterial puncture or non--compressible sitecompressible site-- Aspirin or heparin administered in last 24 hours after acute iscAspirin or heparin administered in last 24 hours after acute ischaemic haemic

strokestroke


Fibrinolytic Therapy (Thrombolytics)Fibrinolytic Therapy (Thrombolytics)Adult Dose:Adult Dose:-- Variable depending on fibrinolytic agent usedVariable depending on fibrinolytic agent used



Morphine Sulphate (MSOMorphine Sulphate (MSO44))Therapeutic Effects:Therapeutic Effects:-- Narcotic analgesic that promotes, through itNarcotic analgesic that promotes, through it’’s vasodilatory effects, s vasodilatory effects,

systemic venous pooling, reducing presystemic venous pooling, reducing pre--load (venous return) as well load (venous return) as well as systemic vascular resistance (after load)as systemic vascular resistance (after load)

-- Reduces myocardial oxygen demand, and consumptionReduces myocardial oxygen demand, and consumption

-- Reduces chest pain and anxietyReduces chest pain and anxiety


Morphine Sulphate (MSOMorphine Sulphate (MSO44))Indications:Indications:-- Chest pain in ACS that is not responsive totally to GTNChest pain in ACS that is not responsive totally to GTN-- Cardiogenic pulmonary oedema, (BP > 90mmHg)Cardiogenic pulmonary oedema, (BP > 90mmHg)

ContraContra--Indications:Indications:-- Hypersensitivity to Morphine or opiate based medicationsHypersensitivity to Morphine or opiate based medications-- Signs of CNS depression (Signs of CNS depression (EgEg: respiratory depression, hypotension, : respiratory depression, hypotension,

bradycardia)bradycardia)


Morphine Sulphate (MSOMorphine Sulphate (MSO44))

Adult Dose:Adult Dose:-- 2 2 –– 4mg4mg via slow IV push, over via slow IV push, over 1 1 –– 5 minutes5 minutes, ,

-- May be repeated every 5 May be repeated every 5 –– 30 minutes30 minutes, to acquire the desired effect , to acquire the desired effect -- Should signs of CNS depression occur, including respiratory deprShould signs of CNS depression occur, including respiratory depression, ession, -- NaloxoneNaloxone ((NarcanNarcan) ) 0.4mg 0.4mg –– 2.0mg2.0mg should be administered IV or IMI to should be administered IV or IMI to

reverse effectsreverse effects


Glyceryl Trinitrate Glyceryl Trinitrate

Therapeutic Effects:Therapeutic Effects:-- Smooth muscle relaxant, producing systemic venous pooling of bloSmooth muscle relaxant, producing systemic venous pooling of blood od

through itthrough it’’s vasodilatory effectss vasodilatory effects

-- Reducing preReducing pre--load (venous return) as well as systemic vascular load (venous return) as well as systemic vascular resistance (after load)resistance (after load)

-- Reduces myocardial oxygen demand, and consumptionReduces myocardial oxygen demand, and consumption


Glyceryl Trinitrate Glyceryl Trinitrate Indications:Indications:-- Chest pain suspected of cardiac in originChest pain suspected of cardiac in origin-- Cardiogenic pulmonary oedema to left sided CHFCardiogenic pulmonary oedema to left sided CHF

ContraContra--Indications:Indications:-- Systolic BP Systolic BP <90mmHg<90mmHg-- Severe Severe Bradycardia <50 bpmBradycardia <50 bpm or or Tachycardia >100bpmTachycardia >100bpm-- Use of Use of ““ViagraViagra”” in last 24 hours in last 24 hours -- Or Or ““CialisCialis”” in last 48 hoursin last 48 hours


Glyceryl Trinitrate Glyceryl Trinitrate Adult Dose:Adult Dose:-- TabletTablet

-- 0.4mg0.4mg sublinguallysublingually-- If not had before or If not had before or > 65 > 65 y/oy/o give half tablet firstgive half tablet first

-- SpraySpray-- 0.4mg (1 spray)0.4mg (1 spray) given given every 5 minutesevery 5 minutes, up to , up to maximum of 3 spraysmaximum of 3 sprays

-- IV InfusionIV Infusion-- 1010--20mcg,20mcg, titrated for effect, titrated for effect, -- Frequently monitor Frequently monitor BP to maintain >90mmHgBP to maintain >90mmHg


Oxygen (OOxygen (O22))Therapeutic effect:Therapeutic effect:-- Increases haemoglobin saturationIncreases haemoglobin saturation

-- Enhances tissue oxygenation, provided that adequate ventilation Enhances tissue oxygenation, provided that adequate ventilation and and circulation are maintainedcirculation are maintained

-- Increase oxygen surface tension in bloodIncrease oxygen surface tension in blood


Oxygen (OOxygen (O22))Indications:Indications:-- Any suspected, cardiovascular, cerebrovascular or respiratory syAny suspected, cardiovascular, cerebrovascular or respiratory system stem

emergencyemergency-- Chest painChest pain-- StrokeStroke-- Altered mental statusAltered mental status-- SOBSOB-- Anyone where it is felt it is needed!Anyone where it is felt it is needed!

ContraContra--Indications:Indications:-- None when given in emergency situationsNone when given in emergency situations


Oxygen (OOxygen (O22))Dose/Method of Administration:Dose/Method of Administration:-- Mild hypoxia with adequate breathingMild hypoxia with adequate breathing

-- Nasal cannula @ Nasal cannula @ 4lpm4lpm

-- Severe hypoxia with adequate breathingSevere hypoxia with adequate breathing-- Non reNon re--breathing mask @ breathing mask @ 15lpm15lpm

-- Inadequate breathing or apnoeaInadequate breathing or apnoea-- Bag valve mask resuscitator (BVM) and reservoir bag @ Bag valve mask resuscitator (BVM) and reservoir bag @ 15lpm15lpm



AntiAnti--ArrhythmicsArrhythmicsIntroduction:Introduction:

Used to treat a variety of arrhythmiaUsed to treat a variety of arrhythmia’’s both supraventricular (narrow) s both supraventricular (narrow) and ventricular (wide) in origin.and ventricular (wide) in origin.-- AdenosineAdenosine-- AmiodaroneAmiodarone-- Lidocaine/LignocaineLidocaine/Lignocaine-- Magnesium SulphateMagnesium Sulphate-- ProcainamideProcainamide


AdenosineAdenosineTherapeutic Effects:Therapeutic Effects:-- Natural occurring endogenous nucleoside that is rapidly metaboliNatural occurring endogenous nucleoside that is rapidly metabolised.sed.

-- Slows discharge rate of SA node and the conduction through the ASlows discharge rate of SA node and the conduction through the AV V nodenode

-- Restoring sinus rhythm in SVTRestoring sinus rhythm in SVT

Indications:Indications:-- Narrow QRS supraventricular tachycardiaNarrow QRS supraventricular tachycardia’’ss

-- SVT to slow the rate to determine underlying rhythmSVT to slow the rate to determine underlying rhythm


AdenosineAdenosineContraContra--Indications:Indications:

-- Toxin induced tachycardiaToxin induced tachycardia’’s (sepsis, crush injury)s (sepsis, crush injury)

-- 22ndnd or 3or 3rdrd degree AV blockdegree AV block

-- Atrial fibrillation or flutterAtrial fibrillation or flutter

-- Wide QRS VTWide QRS VT


AdenosineAdenosineAdult Dose:Adult Dose:-- Initial Dose:Initial Dose:

-- 6mg 6mg rapid (1rapid (1--3 seconds) IV push, with extremity elevated, followed by 3 seconds) IV push, with extremity elevated, followed by 20ml IV saline flush20ml IV saline flush

-- Repeat Dose:Repeat Dose:-- 12mg12mg rapid IV push, rapid IV push, 11--2 minutes after initial dose2 minutes after initial dose, further , further 12mg 12mg dose dose

may be repeated, may be repeated, 11--2 minutes later2 minutes later-- Up to a Up to a maximum of 30mgmaximum of 30mg


Amiodarone:Amiodarone:Therapeutic Effects:Therapeutic Effects:-- Diverse antiDiverse anti--arrhythmic, blocks sodium, calcium and potassium, and arrhythmic, blocks sodium, calcium and potassium, and

inhibits sympathetic nervous system stimulation.inhibits sympathetic nervous system stimulation.

-- Suppressing SA node discharge, reducing heart rateSuppressing SA node discharge, reducing heart rate

-- Slows conduction through AV nodeSlows conduction through AV node

-- Effective in slowing conduction in accessory pathways in WPW Effective in slowing conduction in accessory pathways in WPW syndrome.syndrome.


Amiodarone:Amiodarone:Indications:Indications:-- ““VV””--Fib and Pulseless VT that is refractory to defibrillationFib and Pulseless VT that is refractory to defibrillation-- Polymorphic Polymorphic ““VV””--Tach and wide complex tachycardia of unknown Tach and wide complex tachycardia of unknown

originorigin-- Stable Stable ““VV””--Tach when cardioversion is unsuccessfulTach when cardioversion is unsuccessful-- Adjunct to synchronised cardioversion in supraventricular Adjunct to synchronised cardioversion in supraventricular

tachycardiatachycardia’’s (Atrial Fibrillation)s (Atrial Fibrillation)-- Termination of atrial tachycardiaTermination of atrial tachycardia-- Rate control in atrial fibrillation and atrial flutter, when othRate control in atrial fibrillation and atrial flutter, when other er

therapies have proven unsuccessfultherapies have proven unsuccessful


Amiodarone:Amiodarone:ContraContra--Indications:Indications:-- Known hypersensitivityKnown hypersensitivity

-- Sinus node disease with significant bradycardiaSinus node disease with significant bradycardia

-- 22ndnd and 3and 3rdrd degree AV blockdegree AV block

Pharmacologic and Electrical Pharmacologic and Electrical TherapyTherapyAcute Coronary Syndrome Acute Coronary Syndrome –– PharmacologyPharmacologyAmiodarone:Amiodarone:Adult Dose:Adult Dose:-- V Fib and Pulseless V TachV Fib and Pulseless V Tach

-- 300mg300mg diluted in diluted in 2020--30ml 30ml of of DD55W W via rapid IV pushvia rapid IV push-- May repeat May repeat 150mg150mg diluted in diluted in 2020--30ml30ml of of DD55W W via rapid IV push via rapid IV push 33--5 min5 min

intervalsintervals

-- Stable V Tach, SVT and Atrial flutter/fibrillationStable V Tach, SVT and Atrial flutter/fibrillation-- 150mg 150mg diluted in diluted in 2020--30ml30ml of of DD55WW via rapid IV push over via rapid IV push over 10 minutes10 minutes-- May be May be repeated every 10 minutesrepeated every 10 minutes as requiredas required

-- 24 hour maintenance infusion24 hour maintenance infusion-- 360mg 360mg via IV infusion over first via IV infusion over first 6 hours (1mg/min)6 hours (1mg/min)-- 540mg 540mg over over remaining 18 hoursremaining 18 hours via IV infusion via IV infusion (0.5mg/min)(0.5mg/min)-- Up to a maximum of Up to a maximum of 2.2 grams in 24 hours2.2 grams in 24 hours


Lidocaine / XylocardLidocaine / XylocardTherapeutic Effects:Therapeutic Effects:

-- Blocks influx of sodium through fast channels of myocardium, decBlocks influx of sodium through fast channels of myocardium, decreasing reasing irritability in ischaemic areasirritability in ischaemic areas

-- Increases VIncreases V--Fib threshold, Fib threshold, -- Lidocaine decreases defibrillation thresholdLidocaine decreases defibrillation threshold

Indications:Indications:-- VV--Fib and Pulseless VT refractory to defibrillationFib and Pulseless VT refractory to defibrillation-- Stable wide complex tachycardiaStable wide complex tachycardia’’s (e.g. Vs (e.g. V--TachTach, wide complex , wide complex

tachycardiatachycardia’’s of uncertain origin)s of uncertain origin)


Lidocaine / XylocardLidocaine / XylocardContraContra--Indications:Indications:

-- Known hypersensitivity to Lidocaine or any Known hypersensitivity to Lidocaine or any ““caincain”” based medications based medications (e.g. (e.g. MarcainMarcain etc)etc)

-- Sinus bradycardiaSinus bradycardia

-- AV BlocksAV Blocks


Lidocaine / XylocardLidocaine / XylocardAdult Dose:Adult Dose:-- VV--Fib and Pulseless VFib and Pulseless V--TachTach

-- 11--1.5mg/kg1.5mg/kg via rapid IV pushvia rapid IV push-- May be repeated at May be repeated at 0.50.5--0.75mg/kg0.75mg/kg every every 55--10mins10mins, to a , to a maximum of maximum of

3mg/kg3mg/kg

-- Stable VStable V--TachTach and wide complex tachycardia of unknown originand wide complex tachycardia of unknown origin-- 11--1.5mg/kg 1.5mg/kg via rapid IV pushvia rapid IV push-- May be repeated at May be repeated at 0.50.5--0.75mg/kg 0.75mg/kg every every 55--10mins10mins, to a , to a maximum of maximum of

3mg/kg3mg/kg

-- Maintenance InfusionMaintenance Infusion-- 11--4mg4mg per minute, titrated to desired effectper minute, titrated to desired effect


Magnesium SulphateMagnesium SulphateTherapeutic Effects:Therapeutic Effects:

-- Classified as an electrolyte, possesses an antiClassified as an electrolyte, possesses an anti--arrhythmic type arrhythmic type propertyproperty

-- Slows SA node impulse rate, and suppresses automaticity in Slows SA node impulse rate, and suppresses automaticity in partially depolarised cellspartially depolarised cells

-- Has CNS depressant properties Has CNS depressant properties

-- Indications:Indications:-- TorsadeTorsade de Pointes (TdP) with pulsede Pointes (TdP) with pulse-- Cardiac arrest only if Torsades or Hypomagnesaemia is presentCardiac arrest only if Torsades or Hypomagnesaemia is present


Magnesium SulphateMagnesium SulphateContraContra--Indications:Indications:

-- CNS depressionCNS depression-- HypomagnesaemiaHypomagnesaemia-- HypocalcaemiaHypocalcaemia

Adult Dose:Adult Dose:-- Torsades with PulseTorsades with Pulse

-- Loading dose of Loading dose of 1 1 --2 g2 g mixed in mixed in 5050--100ml100ml of of DD55WW given over given over 55--60 min60 min-- Follow byFollow by 0.50.5--1g/hr 1g/hr IV, titrated to control Torsades de PointesIV, titrated to control Torsades de Pointes

-- Cardiac Arrest (From Hypomagnesaemia or Torsades)Cardiac Arrest (From Hypomagnesaemia or Torsades)-- 11--2g (22g (2--4ml of 50% solution)4ml of 50% solution) diluted indiluted in 10ml 10ml of of DD55W W given IV overgiven IV over 55--

20mins20mins


Procainamide (Pronestyl)Procainamide (Pronestyl)Therapeutic Effects:Therapeutic Effects:

-- Slows conduction of the atria, ventricles and Slows conduction of the atria, ventricles and ““HISHIS”” bundle, bundle, -- Prolonging PProlonging P--R and QR and Q--T intervals and refractory period of AV T intervals and refractory period of AV

nodenode-- Slows refractory period within the atriaSlows refractory period within the atria

Indications:Indications:-- Recurrent VRecurrent V--Fib or Pulseless VFib or Pulseless V--TachTach-- Stable SVT uncontrolled by vagal manoeuvres or adenosineStable SVT uncontrolled by vagal manoeuvres or adenosine-- Atrial fibrillation with rapid ventricular rate in WPWAtrial fibrillation with rapid ventricular rate in WPW


Procainamide (Pronestyl)Procainamide (Pronestyl)ContraContra--Indications:Indications:

-- Known hypersensitivity to procainamide or similar medicationsKnown hypersensitivity to procainamide or similar medications

-- 33rdrd degree AV block (without artificial pacemaker)degree AV block (without artificial pacemaker)

-- Digitalis toxicity (may exacerbate AV conduction depression)Digitalis toxicity (may exacerbate AV conduction depression)

-- PrePre--existing QRS and Qexisting QRS and Q--T interval prolongationT interval prolongation


Procainamide (Pronestyl)Procainamide (Pronestyl)Adult Dose:Adult Dose:-- Recurrent VRecurrent V--Fib and Pulseless VFib and Pulseless V--TachTach

-- 20mg/min20mg/min via IV infusionvia IV infusion-- In urgent situations, up to In urgent situations, up to 50mg/min50mg/min may be administered, may be administered,

-- Use of procainamide in cardiac arrest is limited by need for sloUse of procainamide in cardiac arrest is limited by need for slow IV w IV infusion and uncertain efficacyinfusion and uncertain efficacy

-- SVT, AF, and wide complex tachycardia of unknown originSVT, AF, and wide complex tachycardia of unknown origin-- 20mg/min 20mg/min via IV infusionvia IV infusion

-- Maintenance InfusionMaintenance Infusion-- 11--4mg/min 4mg/min titrated to desired effecttitrated to desired effect


Procainamide (Pronestyl)Procainamide (Pronestyl)Adult Dose:Adult Dose:-- Stop procainamide infusion if:Stop procainamide infusion if:

-- Arrhythmia suppressionArrhythmia suppression-- Hypotension developsHypotension develops-- QRS complex widens > 50% of itQRS complex widens > 50% of it’’s pres pre--treatment widthtreatment width-- Maximum dose of 17mg/kg has been givenMaximum dose of 17mg/kg has been given



Calcium Channel BlockersCalcium Channel BlockersIntroduction:Introduction:

-- Calcium Channel Blockers are used in the treatment of stable narCalcium Channel Blockers are used in the treatment of stable narrow row complex tachycardia'scomplex tachycardia's

-- As well as the rate control in atrial fibrillation and atrial flAs well as the rate control in atrial fibrillation and atrial flutterutter

Pharmacologic and Electrical Pharmacologic and Electrical TherapyTherapyAcute Coronary Syndrome Acute Coronary Syndrome –– PharmacologyPharmacologyDiltiazem (Cardizem)Diltiazem (Cardizem)

Therapeutic Effects:Therapeutic Effects:-- Blocks movement of calcium ions, across cell membranes of Blocks movement of calcium ions, across cell membranes of

myocardium and smooth musclemyocardium and smooth muscle

-- Results in decreased myocardial contractility (negative inotropyResults in decreased myocardial contractility (negative inotropy) )

-- Slowing of conduction through AV node (negative dromotropy)Slowing of conduction through AV node (negative dromotropy)

-- Dilation of coronary arteries and peripheral vasculature, decreaDilation of coronary arteries and peripheral vasculature, decreasing sing myocardial oxygen demandmyocardial oxygen demand


Indications:Indications:-- Control of ventricular rate in atrial fibrillation and atrial flControl of ventricular rate in atrial fibrillation and atrial flutterutter-- Adjunct to adenosine to treat stable narrow complex tachycardiaAdjunct to adenosine to treat stable narrow complex tachycardia’’ss

ContraContra--Indications:Indications:-- Wide complex tachycardiaWide complex tachycardia’’s of unknown origins of unknown origin-- Poison or drug induced tachycardiaPoison or drug induced tachycardia’’ss-- Rapid AF and atrial flutter in WPWRapid AF and atrial flutter in WPW-- Sinus node diseaseSinus node disease-- AV block (without an artificial pacemaker)AV block (without an artificial pacemaker)-- Concurrent use of beta blocking agents (e.g. Atenolol, Inderal)Concurrent use of beta blocking agents (e.g. Atenolol, Inderal)

-- May precipitate significant hypotensionMay precipitate significant hypotension


Adult Dose:Adult Dose:-- IV Bolus:IV Bolus:

-- 1515--20mg (0.25mg/kg)20mg (0.25mg/kg) IV over 2 minutesIV over 2 minutes-- May beMay be repeated 15 minutesrepeated 15 minutes later, atlater, at 2020--25mg (0.35mg/kg)25mg (0.35mg/kg) over over

2 minutes2 minutes-- Maintenance Infusion:Maintenance Infusion:

-- 55--15mg/hour15mg/hour titrated to desired effecttitrated to desired effect

Pharmacologic and Electrical Pharmacologic and Electrical TherapyTherapyAcute Coronary Syndrome Acute Coronary Syndrome –– PharmacologyPharmacologyVerapamil (Calan, Isoptin)Verapamil (Calan, Isoptin)

Therapeutic Effects:Therapeutic Effects:-- Blocks movement of calcium ions across cell membranes and smoothBlocks movement of calcium ions across cell membranes and smooth

muscle of vasculaturemuscle of vasculature

-- Results in decreased myocardial contractility,Results in decreased myocardial contractility,

-- Slowing AV conduction through AV node and dilation of coronary Slowing AV conduction through AV node and dilation of coronary arteries and peripheral vasculature arteries and peripheral vasculature

-- Decreases myocardial oxygen demandDecreases myocardial oxygen demand


Indications:Indications:-- Control of ventricular rate in atrial fibrillation and atrial flControl of ventricular rate in atrial fibrillation and atrial flutter and utter and

ectopic atrial tachycardiaectopic atrial tachycardia-- Adjunct to adenosine to treat stable narrow complex tachycardiaAdjunct to adenosine to treat stable narrow complex tachycardia’’ss

ContraContra--Indications:Indications:-- Wide complex tachycardiaWide complex tachycardia’’s of unknown origins of unknown origin-- Poison or drug induced tachycardiaPoison or drug induced tachycardia’’ss-- Rapid AF and atrial flutter in WPWRapid AF and atrial flutter in WPW-- Sinus node diseaseSinus node disease-- AV block (without an artificial pacemaker)AV block (without an artificial pacemaker)-- Concurrent use of beta blocking agents (e.g. Atenolol, Inderal)Concurrent use of beta blocking agents (e.g. Atenolol, Inderal)

-- May precipitate significant hypotensionMay precipitate significant hypotension

Pharmacologic and Electrical Pharmacologic and Electrical TherapyTherapyAcute Coronary Syndrome Acute Coronary Syndrome –– PharmacologyPharmacologyVerapamil (Calan, Isoptin)Verapamil (Calan, Isoptin)

Adult Dose:Adult Dose:-- 2.52.5--5mg via IV push over 2 minutes5mg via IV push over 2 minutes

-- May be repeated May be repeated 55--10mg10mg via IV push every via IV push every 1515--30 mins30 mins-- MaximumMaximum dose dose 20mg20mg

-- Alternative dosing regimeAlternative dosing regime-- 5mg 5mg via IV push everyvia IV push every 15 minutes15 minutes-- Maximum Maximum dose dose 30mg30mg

Pharmacologic and Electrical Pharmacologic and Electrical TherapyTherapyElectricalElectrical TherapyTherapy

IntroductionIntroduction-- Electrical therapy is frequently usedElectrical therapy is frequently used

-- Where serious S & S as a result of patients cardiac rhythmWhere serious S & S as a result of patients cardiac rhythm

-- Patients with heart beat too fast or too slow, chaotic or pulselPatients with heart beat too fast or too slow, chaotic or pulselessess

-- Need prompt electrical therapy to stabilise their conditionNeed prompt electrical therapy to stabilise their condition

Pharmacologic and Electrical Pharmacologic and Electrical TherapyTherapyDefibrillation:Defibrillation:

Therapeutic Effects:Therapeutic Effects:

-- Unsynchronised delivery of energy into myocardiumUnsynchronised delivery of energy into myocardium

-- To stop chaotic electrical activity by literally freezing the heTo stop chaotic electrical activity by literally freezing the heart in art in animationanimation

-- So an organised SA or AV pacemaker can dominate and restore a So an organised SA or AV pacemaker can dominate and restore a perfusing rhythmperfusing rhythm


Indications:Indications:-- VV--Fib and Pulseless VFib and Pulseless V--TachTach-- Unstable polymorphic VUnstable polymorphic V--TachTach

ContraContra--Indications:Indications:-- AsystoleAsystole

-- Routine defibrillation of asystole is not recommended, because iRoutine defibrillation of asystole is not recommended, because it t may result in failure to identify and treat underlying cause of may result in failure to identify and treat underlying cause of asystoleasystole

-- Regular cardiac rhythm with a pulseRegular cardiac rhythm with a pulse-- Other health care providers being in physical contact with the Other health care providers being in physical contact with the

patientpatient-- Ensure no one is in contact with patient at time of defibrillatiEnsure no one is in contact with patient at time of defibrillationon


Adult Energy Settings:Adult Energy Settings:-- VV--Fib or Pulseless VFib or Pulseless V--TachTach

-- 360J 360J (or biphasic equivalent) for first and subsequent shocks(or biphasic equivalent) for first and subsequent shocks-- Follow each shock immediately with CPRFollow each shock immediately with CPR

-- Reassess after 2 minutes CPRReassess after 2 minutes CPR

-- If first defibrillation unsuccessful, defibrillate one time, as If first defibrillation unsuccessful, defibrillate one time, as needed, after every 2 minutes of CPRneeded, after every 2 minutes of CPR

-- Unstable polymorphic VUnstable polymorphic V--TachTach-- 360J 360J (or biphasic equivalent) repeated as needed(or biphasic equivalent) repeated as needed-- Be prepared to perform CPR if patient becomes pulselessBe prepared to perform CPR if patient becomes pulseless

Pharmacologic and Electrical Pharmacologic and Electrical TherapyTherapySynchronised CardioversionSynchronised Cardioversion

Therapeutic Effects:Therapeutic Effects:-- Timed delivery of energy into myocardiumTimed delivery of energy into myocardium

-- To correct rapid, regular cardiac rhythms, in patients who are To correct rapid, regular cardiac rhythms, in patients who are unstable as a result of cardiac rhythmunstable as a result of cardiac rhythm

-- An internal An internal ““synchronisersynchroniser”” times the shock to deliver when it senses times the shock to deliver when it senses the the ““RR”” wavewave

-- Avoids the shock during the refractory period (down slope of theAvoids the shock during the refractory period (down slope of the ““TT””wave) which may precipitate Vwave) which may precipitate V--Fib Fib

Pharmacologic and Electrical Pharmacologic and Electrical TherapyTherapySynchronised CardioversionSynchronised Cardioversion

Indications:Indications:-- Perfusing narrow and wide QRS complex tachycardiaPerfusing narrow and wide QRS complex tachycardia’’s, >150bpm with s, >150bpm with

serious S & S linked to tachycardiaserious S & S linked to tachycardia-- Monomorphic VMonomorphic V--TachTach, SVT, AF, Atrial Flutter , SVT, AF, Atrial Flutter

ContraContra--Indications:Indications:-- VV--Fib or pulseless VT (Requires Defibrillation)Fib or pulseless VT (Requires Defibrillation)-- Poison or drug induced tachycardiaPoison or drug induced tachycardia

-- Treat underlying problem with an antidote if availableTreat underlying problem with an antidote if available-- The serious symptoms are associated with poison or drug not The serious symptoms are associated with poison or drug not

tachycardiatachycardia-- Other health care providers being in physical contact with the pOther health care providers being in physical contact with the patientatient

-- Ensure no one is in contact with patient at time of defibrillatiEnsure no one is in contact with patient at time of defibrillationon


Adult Energy Settings:Adult Energy Settings:-- Monomorphic VMonomorphic V--TachTach and AFand AF

-- Start with Start with 100J 100J (or biphasic equivalent) (or biphasic equivalent) -- Repeat at Repeat at 200J, 300J, 360J200J, 300J, 360J respectively if the rhythm is not correctedrespectively if the rhythm is not corrected

-- SVT and Atrial FlutterSVT and Atrial Flutter-- Start with Start with 50J,50J, (or biphasic equivalent)(or biphasic equivalent)-- Repeat at Repeat at 100J, 200J, 300J, 360J100J, 200J, 300J, 360J respectively if the rhythm is not respectively if the rhythm is not

correctedcorrected

Pharmacologic and Electrical Pharmacologic and Electrical TherapyTherapyTranscutaneousTranscutaneous Cardiac Pacing:Cardiac Pacing:

Therapeutic Effects:Therapeutic Effects:

-- Uses an artificial electrical impulse to increase electrical disUses an artificial electrical impulse to increase electrical discharge charge rate of slow inherent pace maker in the heartrate of slow inherent pace maker in the heart

-- Preferred initial cardiac pacing method in emergency cardiac carPreferred initial cardiac pacing method in emergency cardiac care e because it is quickly initiated and relatively safebecause it is quickly initiated and relatively safe

Pharmacologic and Electrical Pharmacologic and Electrical TherapyTherapyTranscutaneousTranscutaneous Cardiac Pacing (TCP):Cardiac Pacing (TCP):

Indications:Indications:-- Symptomatic bradycardia, where S & S are related to bradycardia,Symptomatic bradycardia, where S & S are related to bradycardia,

non reactive to atropine or if unavailablenon reactive to atropine or if unavailable-- Rhythms that may require TCP:Rhythms that may require TCP:

-- AV Blocks (Especially 2AV Blocks (Especially 2ndnd and 3and 3rdrd degree)degree)-- Bradycardia with ventricular escape beats (PVCBradycardia with ventricular escape beats (PVC’’s)s)

ContraContra--Indications:Indications:-- Severe hypothermiaSevere hypothermia-- Prolonged bradyProlonged brady--asystolic cardiac arrestasystolic cardiac arrest


Adult Energy Settings:Adult Energy Settings:-- Set pacing rate at 80bpmSet pacing rate at 80bpm-- Symptomatic BradycardiaSymptomatic Bradycardia

-- Increase output (Increase output (mAmA) from minimum setting until consistent capture is ) from minimum setting until consistent capture is achievedachieved

-- Is evidenced by a widening QRS and broad Is evidenced by a widening QRS and broad ““TT”” wave after each pacing wave after each pacing spike.spike.

-- Then increase by 2 Then increase by 2 mAmA as a safety margin to ensure positive captureas a safety margin to ensure positive capture


Pharmacologic and Electrical Pharmacologic and Electrical TherapyTherapyParasympatholytics:Parasympatholytics:

Introduction:Introduction:-- Referred to as parasympathetic blockers, vagolytic and Referred to as parasympathetic blockers, vagolytic and

anticholinergic drugsanticholinergic drugs-- Parasympatholytics block the parasympathetic nervous system, viaParasympatholytics block the parasympathetic nervous system, via

the vagus nervethe vagus nerve-- Used to treat symptomatic bradycardiaUsed to treat symptomatic bradycardia’’s (absolute or relative) s (absolute or relative)

caused by increased vagal tonecaused by increased vagal tone

Pharmacologic and Electrical Pharmacologic and Electrical TherapyTherapyParasympatholytics:Parasympatholytics:Atropine SulphateAtropine Sulphate

Indications:Indications:-- Symptomatic bradycardia (absolute or relative)Symptomatic bradycardia (absolute or relative)-- AsystoleAsystole-- Bradycardic pulseless electrical activity (PEA)Bradycardic pulseless electrical activity (PEA)

ContraContra--Indications:Indications:-- Glaucoma (causes pupillary dilation)Glaucoma (causes pupillary dilation)-- May not be effective in treating bradycardiaMay not be effective in treating bradycardia associated with 2associated with 2ndnd

degree type II and 3degree type II and 3rdrd degree AV blocksdegree AV blocks-- TachycardiaTachycardia-- Denervated (transplanted) hearts, use TCPM and catecholamine's Denervated (transplanted) hearts, use TCPM and catecholamine's

insteadinstead

Pharmacologic and Electrical Pharmacologic and Electrical TherapyTherapySympathomimeticsSympathomimetics

Introduction:Introduction:-- Mimic the effects of the sympathetic nervous systemMimic the effects of the sympathetic nervous system

-- Increasing heart rate and blood pressureIncreasing heart rate and blood pressure

-- Synthetically producedSynthetically produced

-- Equivalent to endogenous bases that occurs in human body naturalEquivalent to endogenous bases that occurs in human body naturallyly

Pharmacologic and Electrical Pharmacologic and Electrical TherapyTherapySympathomimetics:Sympathomimetics:Epinephrine (Adrenaline):Epinephrine (Adrenaline):

Therapeutic Effects:Therapeutic Effects:-- Naturally occurring catecholamine, contains natural occurring AlNaturally occurring catecholamine, contains natural occurring Alpha pha

and Beta adrenergic effectsand Beta adrenergic effects

-- Alpha effects result in vasoconstriction, increasing blood pressAlpha effects result in vasoconstriction, increasing blood pressureure

-- BetaBeta11 effects result in increased heart rate (positive chronotropy) aeffects result in increased heart rate (positive chronotropy) and nd increased myocardial contractility (positive inotropy)increased myocardial contractility (positive inotropy)

-- BetaBeta22 effects cause relaxation of bronchial smooth muscle, effects cause relaxation of bronchial smooth muscle, (bronchodilation)(bronchodilation)


Indications:Indications:-- Cardiac ArrestCardiac Arrest

-- VV--Fib or Pulseless VFib or Pulseless V--TachTach

-- Symptomatic BradycardiaSymptomatic Bradycardia-- After atropine and pacingAfter atropine and pacing

-- Severe hypotensionSevere hypotension-- Treat with fluid boluses firstTreat with fluid boluses first

-- Anaphylactic ShockAnaphylactic Shock-- Combined with fluid bolus, corticosteroids and antihistaminesCombined with fluid bolus, corticosteroids and antihistamines


ContraContra-- Indications:Indications:-- Tachycardia Tachycardia

-- HypertensionHypertension

-- Do not mixDo not mix with alkaline solutions,with alkaline solutions, (e.g. sodium bicarbonate) (e.g. sodium bicarbonate) deactivation will occur, as will, with all catecholamine's.deactivation will occur, as will, with all catecholamine's.


Adult Dose:Adult Dose:-- Cardiac Arrest:Cardiac Arrest:

-- 1mg (10ml of 1:10,000)1mg (10ml of 1:10,000) every every 33--5mins5mins, followed by, followed by 20ml flush20ml flush of normal of normal salinesaline

-- No maximum doseNo maximum dose when administered forwhen administered for persistent cardiac arrestpersistent cardiac arrest

-- Symptomatic bradycardia or severe hypotensionSymptomatic bradycardia or severe hypotension-- 22--10mcg 10mcg per minuteper minute

-- AddAdd 1mg Adrenaline 1mg Adrenaline (1ml of 1:1000)(1ml of 1:1000) toto 500ml normal saline500ml normal saline and infuse atand infuse at 11--5mL/min5mL/min

Pharmacologic and Electrical Pharmacologic and Electrical TherapyTherapySympathomimetics:Sympathomimetics:Dopamine (Intropin):Dopamine (Intropin):

Therapeutic Effects:Therapeutic Effects:-- Naturally occurring catecholamine, Naturally occurring catecholamine, -- Physiological effects vary with increasing dosesPhysiological effects vary with increasing doses-- At At medium or medium or ““cardiac dosescardiac doses”” (5(5--10mcg/kg/min),10mcg/kg/min), dopamine acts dopamine acts

directly on directly on beta receptorsbeta receptors-- Causing increased myocardial contractility, (increased inotropy)Causing increased myocardial contractility, (increased inotropy), and , and

increased SA nodal discharge and increased heart rate (positive increased SA nodal discharge and increased heart rate (positive chronotropy)chronotropy)

-- Doses Doses > 10mcg/kg/min> 10mcg/kg/min (vasopressor dose) (vasopressor dose) stimulate Alpha stimulate Alpha receptorsreceptors, increasing systemic vascular resistance (vasoconstriction) , increasing systemic vascular resistance (vasoconstriction)

-- Dosing depends on patients conditionDosing depends on patients condition


Indications:Indications:

-- Symptomatic Bradycardia:Symptomatic Bradycardia:-- After atropine, pacing and adrenalineAfter atropine, pacing and adrenaline

-- Hypotension (Systolic <70Hypotension (Systolic <70--100mmHg) with S & S of shock100mmHg) with S & S of shock-- Consider fluid boluses first, dopamine should not be given when Consider fluid boluses first, dopamine should not be given when

hypovolaemichypovolaemic


ContraContra--Indications:Indications:-- Known hypersensitivityKnown hypersensitivity-- HypolvolaemiaHypolvolaemia-- TachydysrhythmiaTachydysrhythmia’’s or Vs or V--FibFib-- Pheochromocytoma (Adrenal tumor producing adrenaline)Pheochromocytoma (Adrenal tumor producing adrenaline)-- Concurrent use of Concurrent use of MOAIMOAI’’ss-- Do not mixDo not mix with alkaline solutions,with alkaline solutions, (e.g. sodium bicarbonate) (e.g. sodium bicarbonate)

deactivation will occur, as will, with all catecholamine's.deactivation will occur, as will, with all catecholamine's.


Adult Dose:Adult Dose:-- As IV InfusionAs IV Infusion

-- MixMix 400mg400mg--800mg 800mg of dopamine inof dopamine in 250ml 250ml of normal saline, D5W, or of normal saline, D5W, or HartmannHartmann’’ss and titrate on patients clinical responseand titrate on patients clinical response

-- Symptomatic bradycardiaSymptomatic bradycardia-- 22--10mcg/kg/min10mcg/kg/min

-- Profound hypotension (NonProfound hypotension (Non--hypovolaemic)hypovolaemic)-- 1010--20mcg/kg/min 20mcg/kg/min

Pharmacologic and Electrical Pharmacologic and Electrical TherapyTherapySympathomimetics:Sympathomimetics:Vasopressin (Pitressin Synthetic):Vasopressin (Pitressin Synthetic):

Introduction:Introduction:-- Is an AntiIs an Anti--Diuretic Hormone Diuretic Hormone (ADH)(ADH) produced in the pituitary glandproduced in the pituitary gland-- Binds to specific receptors, specifically vasopressin (V) receptBinds to specific receptors, specifically vasopressin (V) receptorsors-- 2 receptors 2 receptors VV11((VV11aa and and VV11bb) and ) and VV22..-- VV11a produces potent vasoconstrictiona produces potent vasoconstriction-- VV22 produces vasodilationproduces vasodilation-- Vasopressin possesses a greater vasoconstrictive effect, especiaVasopressin possesses a greater vasoconstrictive effect, especially in lly in

an acidotic or hypoxic environment (e.g. Cardiac Arrest)an acidotic or hypoxic environment (e.g. Cardiac Arrest)-- Does not increase myocardial oxygen consumptionDoes not increase myocardial oxygen consumption


Indications:Indications:-- Used to replace the first and second dose of adrenaline for patiUsed to replace the first and second dose of adrenaline for patients ents

in cardiac arrest from Vin cardiac arrest from V--Fib/pulseless VFib/pulseless V--TachTach, asystole and PEA, asystole and PEA

ContraContra--Indications:Indications:-- Known sensitivity to vasopressinKnown sensitivity to vasopressin-- Acute Coronary SyndromeAcute Coronary Syndrome

-- Vasopressin may exacerbate hypertension because of itVasopressin may exacerbate hypertension because of it’’s s vasoconstrictive effectsvasoconstrictive effects


Adult Dose:Adult Dose:

-- 40 units40 units via IV push as avia IV push as a one off doseone off dose-- Wait approximately 10 minutes after vasopressin administration bWait approximately 10 minutes after vasopressin administration before efore

initiating/resuming adrenaline therapyinitiating/resuming adrenaline therapy


Assessment of NonAssessment of Non--Cardiac Cardiac Arrest PatientsArrest PatientsIntroduction:Introduction:-- Appropriate and prompt assessment and treatment of the patient Appropriate and prompt assessment and treatment of the patient

experiencing difficulties because of a cardiovascular or respiraexperiencing difficulties because of a cardiovascular or respiratory tory related condition is imperative.related condition is imperative.

Assessment of NonAssessment of Non--Cardiac Cardiac Arrest PatientsArrest PatientsIntroduction:Introduction:-- You must perform a careful and systematic assessment aimed at

identifying serious S&S linked to the patient, or their cardiac rhythm.

Assessment of NonAssessment of Non--Cardiac Cardiac Arrest PatientsArrest PatientsUniversal Treatment of the NONUniversal Treatment of the NON--Cardiac Arrest Cardiac Arrest

PatientPatient

- Certain interventions must be performed on all non cardiac arrest patients, presenting with cardiovascular or respiratory related S&S.- Oxygen- IVT- Pulse Oximetry- 12 lead if available- Cardiac monitoring

Assessment of NonAssessment of Non--Cardiac Cardiac Arrest PatientsArrest PatientsSummary:Summary:-- Patient presenting with S&S of Non cardiac related cardiovasculaPatient presenting with S&S of Non cardiac related cardiovascular or r or

respiratory system emergencies needs a systematic assessment.respiratory system emergencies needs a systematic assessment.-- Your findings will dictate the most appropriate treatmentYour findings will dictate the most appropriate treatment-- All patients require:All patients require:

-- Supplementary oxygen therapySupplementary oxygen therapy-- Cardiac monitoringCardiac monitoring-- Intravenous therapyIntravenous therapy

-- The goal in managing these patients is preventing them from goinThe goal in managing these patients is preventing them from going g into cardiac arrest.into cardiac arrest.

Assessment and treatment of Assessment and treatment of Cardiac Arrest PatientsCardiac Arrest PatientsIntroduction:Introduction:-- Successful management of a patient in cardiac arrest requires a Successful management of a patient in cardiac arrest requires a

careful and systematic assessment, immediate identification of tcareful and systematic assessment, immediate identification of their heir cardiac rhythm and selection of the appropriate treatment.cardiac rhythm and selection of the appropriate treatment.

Assessment and treatment of Assessment and treatment of Cardiac Arrest PatientsCardiac Arrest PatientsAssessing the Underlying causes of Cardiac ArrestAssessing the Underlying causes of Cardiac Arrest-- Careful assessment needs to occur:Careful assessment needs to occur:

-- Pm Pm HxHx –– Past Medical HistoryPast Medical History-- HxHx -- HistoryHistory-- Events leading to incidentEvents leading to incident

-- Management:Management:-- Defibrillation, adrenaline and other pharmacological adjuncts wiDefibrillation, adrenaline and other pharmacological adjuncts will not be ll not be

effective until the underlying cause is identified and rectifiedeffective until the underlying cause is identified and rectified..

-- We use the We use the 6 H6 H’’ss and and TT’’ss to assess the underlying causes.to assess the underlying causes.

Assessment and treatment of Assessment and treatment of Cardiac Arrest PatientsCardiac Arrest PatientsUniversal Treatment of Cardiac ArrestUniversal Treatment of Cardiac Arrest-- Certain interventions must be carried out in all cases of cardiaCertain interventions must be carried out in all cases of cardiac c

arrest regardless of the presenting cardiac rhythm.arrest regardless of the presenting cardiac rhythm.-- CPRCPR-- Endotracheal intubationEndotracheal intubation-- Vascular AccessVascular Access-- VasopressorsVasopressors-- Circulation of cardiac drugsCirculation of cardiac drugs-- Identify and Correct underlying causesIdentify and Correct underlying causes

Assessment and treatment of Assessment and treatment of Cardiac Arrest PatientsCardiac Arrest PatientsPost Cardiac Arrest TreatmentPost Cardiac Arrest Treatment-- If a pulse and perfusing rhythm are successfully restored, you mIf a pulse and perfusing rhythm are successfully restored, you must ust

perform certain interventions to prevent the recurrence of cardiperform certain interventions to prevent the recurrence of cardiac ac arrest. arrest.

-- If the patient reIf the patient re--arrests, the chances of a second successful arrests, the chances of a second successful resuscitation are much lowerresuscitation are much lower

-- Prevention of recurrent cardiac arrest can be maximised by Prevention of recurrent cardiac arrest can be maximised by performing appropriate managementperforming appropriate management

Assessment of NonAssessment of Non--Cardiac Cardiac Arrest PatientsArrest PatientsSummary:Summary:-- You must focus on identifying and correcting the underlying causYou must focus on identifying and correcting the underlying cause of e of

cardiac arrest.cardiac arrest.-- Failure will significantly decrease the likelihood of successfulFailure will significantly decrease the likelihood of successful

resuscitationresuscitation-- Interventions must be performed regardless of underlying rhythmInterventions must be performed regardless of underlying rhythm-- Interventions are aimed at maintaining effective ventilation andInterventions are aimed at maintaining effective ventilation and

circulation until the abnormal rhythm can be correctedcirculation until the abnormal rhythm can be corrected


Case Review 1 Case Review 1 -- ACSACSIntroduction:Introduction:-- Looks at a patient presenting with Acute Coronary Syndrome.Looks at a patient presenting with Acute Coronary Syndrome.-- Term used to describe unstable angina pectoris Term used to describe unstable angina pectoris ““AnginaAngina”” or an acute or an acute

myocardial infarction (AMI).myocardial infarction (AMI).-- Most patients present with chest pain, discomfort, SOB, diaphoreMost patients present with chest pain, discomfort, SOB, diaphoresis, sis,

dyspnoeadyspnoea-- Advised to air on side of caution and suspect AMIAdvised to air on side of caution and suspect AMI

Case Review 1 Case Review 1 -- ACSACSSigns & Symptoms:Signs & Symptoms:

Case Review 1 Case Review 1 -- ACSACSImmediate Treatment & Management:Immediate Treatment & Management:

-- In first 10 mins an immediate assessment and treatment regime In first 10 mins an immediate assessment and treatment regime must occurmust occur

-- Diagnosing patients problem, provide adequate treatmentDiagnosing patients problem, provide adequate treatment

-- Mnemonic Mnemonic –– ““MONAMONA””-- MorphineMorphine-- OxygenOxygen-- NitroNitro--glycerine (GTN)glycerine (GTN)-- AspirinAspirin

Immediate Treatment & Management:Immediate Treatment & Management:

Case Review 1 Case Review 1 -- ACSACSTargeted History for Fibrinolytic Therapy:Targeted History for Fibrinolytic Therapy:-- In conjunction with 12 lead ECGIn conjunction with 12 lead ECG-- Perform brief targeted history and physical examination targetedPerform brief targeted history and physical examination targeted on on

eligibilityeligibility-- If administered within 12 hours of onset of symptoms, If administered within 12 hours of onset of symptoms, ““clot bustersclot busters””

can significantly reduce size of infarct, preserving myocardiumcan significantly reduce size of infarct, preserving myocardium-- The indications or The indications or ““inclusion criteriainclusion criteria”” for therapy must be carefully for therapy must be carefully

matched to matched to contraindicationscontraindications ““exclusion criteriaexclusion criteria””,, if they are if they are administered to administered to wrong patientwrong patient, they can be , they can be lethal.lethal.

Case Review 1 Case Review 1 -- ACSACSTargeted History for Fibrinolytic Therapy:Targeted History for Fibrinolytic Therapy:-- Inclusion criteria:Inclusion criteria:

Case Review 1 Case Review 1 -- ACSACSOther Perfusion Strategies:Other Perfusion Strategies:-- Depending on condition and haemodynamic statusDepending on condition and haemodynamic status-- Other strategies may include:Other strategies may include:

-- Percutaneous Coronary Interventions (PCI) Percutaneous Coronary Interventions (PCI) -- (e.g. Coronary angioplasty with or without stent)(e.g. Coronary angioplasty with or without stent)

-- Coronary Artery Bypass Grafting (CABG) (GAGS)Coronary Artery Bypass Grafting (CABG) (GAGS)

Case Review 1 Case Review 1 -- ACSACSTargeted History for Fibrinolytic Therapy:Targeted History for Fibrinolytic Therapy:-- Exclusion criteria:Exclusion criteria:

Case Review 1 Case Review 1 -- ACSACSSummary:Summary:-- Patient who presents with Patient who presents with S & S of ACSS & S of ACS, requires immediate , requires immediate

assessment within 10 minutes of presentationassessment within 10 minutes of presentation-- 12 lead ECG12 lead ECG-- Cardiac serum markersCardiac serum markers-- Targeted historyTargeted history-- Emphasis on fibrinolytic therapy suitabilityEmphasis on fibrinolytic therapy suitability

-- Immediate management aimed at oxygenation and ventilation with Immediate management aimed at oxygenation and ventilation with pharmacologic interventions to reduce pain and anxietypharmacologic interventions to reduce pain and anxiety

-- The adage The adage ““time is myocardiumtime is myocardium”” definitely applies and should be definitely applies and should be remembered and taken seriously in patients with ACS presentationremembered and taken seriously in patients with ACS presentation


Case Review 2 Case Review 2 -- AsystoleAsystoleIntroduction:Introduction:

-- Asystole represents the absence of both cardiac electrical and Asystole represents the absence of both cardiac electrical and mechanical activity on a cardiac monitormechanical activity on a cardiac monitor

-- Unfortunately asystole is rarely associated with a positive outcUnfortunately asystole is rarely associated with a positive outcomeome

Case Review 2 Case Review 2 -- AsystoleAsystoleTreatment:Treatment:-- Must be assessed in 2 or more leads, as it may be asystole in Must be assessed in 2 or more leads, as it may be asystole in

appearance in one lead and fine Vappearance in one lead and fine V--Fib in anotherFib in another-- CPRCPR-- Airway managementAirway management-- MedicationsMedications-- Assessment as to why the patient is presenting in this wayAssessment as to why the patient is presenting in this way

Case Review 2 Case Review 2 -- AsystoleAsystoleTreatment:Treatment:

Case Review 2 Case Review 2 -- AsystoleAsystoleSummary:Summary:-- It should be considered to be the only true arrhythmia because iIt should be considered to be the only true arrhythmia because it t

represents a total absence of any electrical or mechanical activrepresents a total absence of any electrical or mechanical activity of ity of the heartthe heart

-- Unfortunately is associated with a poor prognosisUnfortunately is associated with a poor prognosis

-- There are potentially reversible causes of asystole, therefore There are potentially reversible causes of asystole, therefore systematic assessment, and appropriate interventions will maximisystematic assessment, and appropriate interventions will maximise se chances of successful resuscitationchances of successful resuscitation


Case Review 3 Case Review 3 –– Automated Automated External DefibrillationExternal DefibrillationIntroduction:Introduction:-- Most cardiac patients present with ventricular fibrillation (VMost cardiac patients present with ventricular fibrillation (V--Fib) as Fib) as

the initial dysrhythmiathe initial dysrhythmia

-- VV--Fib does not produce a pulse, therefore blood is not circulatedFib does not produce a pulse, therefore blood is not circulated

-- Pulseless VPulseless V--TachTach is less common but as lethal as Vis less common but as lethal as V--FibFib

-- The single most effective treatment for VThe single most effective treatment for V--Fib is defibrillationFib is defibrillation

-- VV--Fib is a transient rhythm and rapidly deterioratesFib is a transient rhythm and rapidly deteriorates

-- The AED can provide rapid defibrillation and does not require anThe AED can provide rapid defibrillation and does not require anACLS operator to perform treatmentACLS operator to perform treatment

Case Review 3 Case Review 3 –– Automated Automated External DefibrillationExternal DefibrillationAssessment and Initial Treatment:Assessment and Initial Treatment:

-- A careful and systematic assessment is required for a patient inA careful and systematic assessment is required for a patient incardiac arrest cardiac arrest

-- If arrest was witnessed by you, begin CPR and apply AED If arrest was witnessed by you, begin CPR and apply AED immediately.immediately.

-- If not witnessed perform 2 minutes of CPR prior to applying AEDIf not witnessed perform 2 minutes of CPR prior to applying AED

-- A return of spontaneous circulation (ROSC) occurs more often in A return of spontaneous circulation (ROSC) occurs more often in VV--Fib or Pulseless VFib or Pulseless V--TachTach if 1 if 1 ½½ -- 3 minutes of CPR is conducted prior 3 minutes of CPR is conducted prior to defibrillationto defibrillation

Case Review 3 Case Review 3 –– Automated Automated External DefibrillationExternal DefibrillationCardiac Rhythm Analysis and Defibrillation:Cardiac Rhythm Analysis and Defibrillation:-- As soon as AED is available it must be attachedAs soon as AED is available it must be attached

-- For each minute in VFor each minute in V--Fib and Pulseless VFib and Pulseless V--TachTach defibrillation is defibrillation is delayed, the chance of survival is reduced by 10%delayed, the chance of survival is reduced by 10%

-- If indicated the AED will deliver a single shock, after which CPIf indicated the AED will deliver a single shock, after which CPR R should be continuedshould be continued

-- After 2 minutes the AED will assess the patientAfter 2 minutes the AED will assess the patient’’s rhythm and ask you s rhythm and ask you to check pulse, reanalyse and deliver a shock if indicatedto check pulse, reanalyse and deliver a shock if indicated

Case Review 3 Case Review 3 –– Automated Automated External DefibrillationExternal Defibrillation

Summary:Summary:-- A rapid assessment is required in order to confirm the presence A rapid assessment is required in order to confirm the presence of of

cardiac arrest and begin the appropriate treatment ASAP.cardiac arrest and begin the appropriate treatment ASAP.


Case Review 4 Case Review 4 –– BradycardiaBradycardiaIntroduction:Introduction:-- A careful and systematic approach must occur to determine whetheA careful and systematic approach must occur to determine whether r

serious S & S linked to bradycardia are presentserious S & S linked to bradycardia are present-- Bradycardia can take many formsBradycardia can take many forms

-- Sinus bradycardiaSinus bradycardia-- 11stst, 2, 2ndnd degree and complete heart blocksdegree and complete heart blocks

-- However the important concept to remember is that regardless of However the important concept to remember is that regardless of the rhythm the rate is too slow and if the patient is symptomatithe rhythm the rate is too slow and if the patient is symptomatic it c it must be treated.must be treated.

Case Review 4 Case Review 4 –– BradycardiaBradycardiaAbsolute and Relative Bradycardia:Absolute and Relative Bradycardia:-- Absolute bradycardia exists when the ventricular rate is less thAbsolute bradycardia exists when the ventricular rate is less than 60 an 60

beats per minute, such occurs in sinus bradycardiabeats per minute, such occurs in sinus bradycardia

-- Relative bradycardia exists when the patientRelative bradycardia exists when the patient’’s heart rate is faster s heart rate is faster than one would expect for his/her condition yet the patient is than one would expect for his/her condition yet the patient is unstable.unstable.

-- E.G. A patient who has a heart rate of 65bpm, but a BP of E.G. A patient who has a heart rate of 65bpm, but a BP of 80/50mmHg may be experiencing 80/50mmHg may be experiencing ““relativerelative”” bradycardia because the bradycardia because the pulse relative to BP is too slowpulse relative to BP is too slow

Case Review 4 Case Review 4 –– BradycardiaBradycardiaTreatment of Bradycardia:Treatment of Bradycardia:

-- Treatment depends on the presence or absence of serious S & S.Treatment depends on the presence or absence of serious S & S.

-- The asymptomatic patient may require little more than close The asymptomatic patient may require little more than close monitoring, monitoring,

-- However the unstable patient requires interventions aimed at However the unstable patient requires interventions aimed at increasing the heart rate and improving perfusion.increasing the heart rate and improving perfusion.

Case Review 4 Case Review 4 –– BradycardiaBradycardiaTreatment of Bradycardia:Treatment of Bradycardia:

-- Treatment depends on the presence or absence of serious S & S.Treatment depends on the presence or absence of serious S & S.

-- The asymptomatic patient may require little more than close The asymptomatic patient may require little more than close monitoring, monitoring,

-- However the unstable patient requires interventions aimed at However the unstable patient requires interventions aimed at increasing the heart rate and improving perfusion.increasing the heart rate and improving perfusion.

Case Review 4 Case Review 4 –– BradycardiaBradycardiaSummary:Summary:-- A patient who is asymptomatic requires no more than observationA patient who is asymptomatic requires no more than observation

-- However the patient presenting with serious S & S of inadequate However the patient presenting with serious S & S of inadequate perfusion linked to bradycardia need immediate interventionsperfusion linked to bradycardia need immediate interventions

-- Aimed at increasing the heart rate and preventing cardioAimed at increasing the heart rate and preventing cardio--vascular vascular collapse collapse

-- Remember even though th4 patient may have a heart rate of 60Remember even though th4 patient may have a heart rate of 60--70bpm, if the blood pressure is poor, the cardiac rate is bradyc70bpm, if the blood pressure is poor, the cardiac rate is bradycardic ardic and needs intervention rapidlyand needs intervention rapidly

-- ““AbsoluteAbsolute”” or or ““relativerelative”” bradycardia needs rapid intervention to bradycardia needs rapid intervention to ensure adequate oxygenation and perfusionensure adequate oxygenation and perfusion


Case Review 5 Case Review 5 –– Narrow Complex Narrow Complex TachycardiaTachycardiaIntroduction:Introduction:-- The term The term ““Narrow Complex TachycardiaNarrow Complex Tachycardia”” refers to a rhythm in which refers to a rhythm in which

the QRS complex is less than 0.12 seconds or 3 small boxes on ththe QRS complex is less than 0.12 seconds or 3 small boxes on the e ECG,ECG,

-- The ventricular rate is equal or > 100bpmThe ventricular rate is equal or > 100bpm-- SVT indicates that the origin of the cardiac rhythm is above (suSVT indicates that the origin of the cardiac rhythm is above (supra) pra)

the ventriclesthe ventricles-- SVT manifests as many other rhythms, atrial tachycardia, atrial SVT manifests as many other rhythms, atrial tachycardia, atrial

fibrillation, or flutter with rapid ventricular rate (RVR) and Jfibrillation, or flutter with rapid ventricular rate (RVR) and Junctional unctional tachycardiatachycardia

Case Review 5 Case Review 5 –– Narrow Complex Narrow Complex TachycardiaTachycardiaTreatment:Treatment:-- Careful and systematic assessment must be performed so that the Careful and systematic assessment must be performed so that the

most appropriate treatment can be provided to the patient.most appropriate treatment can be provided to the patient.

-- If the patient is not experiencing serious S & S linked to tachyIf the patient is not experiencing serious S & S linked to tachycardia, cardia,

-- Initial treatment involves interventions aimed at decreasing theInitial treatment involves interventions aimed at decreasing theventricular rate and identifying the underlying cardiac rhythmventricular rate and identifying the underlying cardiac rhythm

-- If serious S & S are present synchronised cardioversion must be If serious S & S are present synchronised cardioversion must be performed without delay.performed without delay.

Case Review 5 Case Review 5 –– Narrow Complex Narrow Complex TachycardiaTachycardiaSummary:Summary:-- PatientPatient’’s with narrow complex tachycardia requires careful and s with narrow complex tachycardia requires careful and

systematic assessmentsystematic assessment-- All patientAll patient’’s require:s require:

-- Supplemental oxygenSupplemental oxygen-- IVTIVT-- Cardiac monitoringCardiac monitoring-- 12 lead if available12 lead if available

-- If the patient is stable, initial treatment is aimed at decreasiIf the patient is stable, initial treatment is aimed at decreasing the ng the heart rate with a combination of vagal manoeuvres and heart rate with a combination of vagal manoeuvres and pharmacologic interventionspharmacologic interventions

-- Unstable patientUnstable patient’’s require immediate synchronised cardioversion, s require immediate synchronised cardioversion, which in the conscious patient should be preceded with a sedativwhich in the conscious patient should be preceded with a sedative e agentagent


Case Review 6 Case Review 6 –– Pulseless Electrical Activity Pulseless Electrical Activity (PEA)(PEA)Introduction:Introduction:-- Patient's with Pulseless Electrical Activity (PEA) , is charactePatient's with Pulseless Electrical Activity (PEA) , is characterised by rised by

a rhythm on the cardiac monitor when the patient does not have aa rhythm on the cardiac monitor when the patient does not have acardiac outputcardiac output

-- Any rhythm can be seen with PEAAny rhythm can be seen with PEA-- Only exception is VOnly exception is V--Fib and Pulseless VFib and Pulseless V--TachTach, both of which were , both of which were

previously mentioned as requiring immediate defibrillationpreviously mentioned as requiring immediate defibrillation

Case Review 6 Case Review 6 –– Pulseless Electrical Activity Pulseless Electrical Activity (PEA)(PEA)Treatment:Treatment:-- In addition to managing cardiac arrest, management focus is on In addition to managing cardiac arrest, management focus is on

identifying the underlying causeidentifying the underlying cause

-- Common causes of cardiac arrest, their clinical signs, their resCommon causes of cardiac arrest, their clinical signs, their respective pective treatments are in treatments are in Table 3Table 3--1414

-- As a general rule, any rhythm that is As a general rule, any rhythm that is slowslow indicates indicates HypoxiaHypoxia

-- Any rhythm Any rhythm fastfast indicate indicate HypolvolaemiaHypolvolaemia

Case Review 6 Case Review 6 –– Pulseless Electrical Activity Pulseless Electrical Activity (PEA)(PEA)Summary:Summary:-- PEA is a phenomenon that could be overlooked if you do not perfoPEA is a phenomenon that could be overlooked if you do not perform rm

a careful assessmenta careful assessment-- Treatment of PEA involves treating cardiac arrest with:Treatment of PEA involves treating cardiac arrest with:

-- CPR CPR -- Airway managementAirway management-- IV TherapyIV Therapy-- And medicationsAnd medications

-- Ultimate goal is to rapidly identify and treat underlying Ultimate goal is to rapidly identify and treat underlying cause(scause(s))


Case Review 7 Case Review 7 –– Respiratory ArrestRespiratory Arrest

Introduction:Introduction:-- You must perform a rapid assessment and management regime in You must perform a rapid assessment and management regime in

patients with respiratory arrestpatients with respiratory arrest

-- Including patients with respiratory arrest as a result of a foreIncluding patients with respiratory arrest as a result of a foreign ign body airway obstruction (FBAO)body airway obstruction (FBAO)

-- Immediate positive pressure ventilations must be provided, whileImmediate positive pressure ventilations must be provided, whilemaintaining airway patencymaintaining airway patency

-- Failure to recognise and immediately treat leads to cardiopulmonFailure to recognise and immediately treat leads to cardiopulmonary ary arrest and death within minutesarrest and death within minutes


Assessment:Assessment:-- Ensure airway is open and patent, clear of secretions, or obstruEnsure airway is open and patent, clear of secretions, or obstructionsctions

-- In the nonIn the non--injured patient, head tilt, chin lift manoeuvre or in the injured patient, head tilt, chin lift manoeuvre or in the patient with suspected spinal injury, the jaw thrust manoeuvrepatient with suspected spinal injury, the jaw thrust manoeuvre

-- Critical the patientCritical the patient’’s airway remains clear at all timess airway remains clear at all times

-- Vomitus and other secretions in the airway require immediate Vomitus and other secretions in the airway require immediate oropharyngeal suctioningoropharyngeal suctioning

-- Assess for spontaneous breathing, evident by rise and fall of thAssess for spontaneous breathing, evident by rise and fall of the e chest and sounds of air exiting the chest, via nose and mouthchest and sounds of air exiting the chest, via nose and mouth


Management:Management:-- Maintain patent airway, with a combination of manual positioningMaintain patent airway, with a combination of manual positioning of of

head and insertion of basic airway adjunct, OPA or NPAhead and insertion of basic airway adjunct, OPA or NPA

-- Positive pressure ventilations are then provided with a bag valvPositive pressure ventilations are then provided with a bag valve e mask (BVM) or a pocket mask at 10 mask (BVM) or a pocket mask at 10 --12 breaths per minute12 breaths per minute

-- In order to deliver high concentrations of oxygen, you must ensuIn order to deliver high concentrations of oxygen, you must ensure re supplemental oxygen is attachedsupplemental oxygen is attached


Foreign Body Airway Obstruction (FBAO):Foreign Body Airway Obstruction (FBAO):-- May be food, can obstruct airway and prevent patient from movingMay be food, can obstruct airway and prevent patient from moving

airair-- Recognised in initial attempts to ventilate, you meet resistanceRecognised in initial attempts to ventilate, you meet resistance

and/or do not see the chest rise and falland/or do not see the chest rise and fall-- This needs to be rectified immediatelyThis needs to be rectified immediately-- Reposition patients headReposition patients head-- Attempt to reAttempt to re--ventilate, If both breaths do not produce visible chest ventilate, If both breaths do not produce visible chest

rise and fall,rise and fall,-- Perform chest compressions in an attempt to clear obstructionPerform chest compressions in an attempt to clear obstruction-- If compressions fail to dislodge airway obstruction, visualise vIf compressions fail to dislodge airway obstruction, visualise vocal ocal

chords with a laryngoscope (direct laryngoscopy) and remove the chords with a laryngoscope (direct laryngoscopy) and remove the obstruction with Magill Forcepsobstruction with Magill Forceps


Endotracheal Intubation:Endotracheal Intubation:-- In an adult patient Endotracheal intubation it is seen to be theIn an adult patient Endotracheal intubation it is seen to be the ““gold gold

standardstandard”” for airway managementfor airway management-- Patients in respiratory or cardiac arrest usually require prolonPatients in respiratory or cardiac arrest usually require prolonged ged

ventilatory support and are at extremely high risk for regurgitaventilatory support and are at extremely high risk for regurgitation tion and aspiration of stomach contentsand aspiration of stomach contents

-- The airway should be protected with an endotracheal tubeThe airway should be protected with an endotracheal tube


Alternate airway management:Alternate airway management:-- Alternate airway management tools include:Alternate airway management tools include:

-- LMA LMA –– Laryngeal mask AirwayLaryngeal mask Airway-- Oesophageal CombitubeOesophageal Combitube


Summary:Summary:-- Ensure airway is open and clear of obstructionsEnsure airway is open and clear of obstructions

-- Confirm absence of breathing, then ventilate with BVM for 2 breaConfirm absence of breathing, then ventilate with BVM for 2 breathsths

-- If initial ventilations unsuccessful, airway obstruction likelyIf initial ventilations unsuccessful, airway obstruction likely

-- Clear obstruction, manually or by laryngoscopyClear obstruction, manually or by laryngoscopy

-- Once airway is patent, continue positive pressure ventilation 10Once airway is patent, continue positive pressure ventilation 10 –– 12 12 breath per minutebreath per minute

-- To secure airway, endotracheal intubation should be performedTo secure airway, endotracheal intubation should be performed

Case Review 8 Case Review 8 –– StrokeStroke

Introduction:Introduction:-- An An ischaemic strokeischaemic stroke is the result of a is the result of a blocked cerebral arteryblocked cerebral artery

-- Common causes include formation of Common causes include formation of local thrombuslocal thrombus or a or a thrombus thrombus that breaks free (embolus)that breaks free (embolus) and travels to brain from another part of and travels to brain from another part of the bodythe body

-- Less common causes Less common causes cerebral arterial vasospasmcerebral arterial vasospasm, and , and generalised generalised hypoperfusion (shock)hypoperfusion (shock)

-- All areas distal of the blocked artery are deprived of oxygen reAll areas distal of the blocked artery are deprived of oxygen resulting sulting in varying degreein varying degree’’s of neurological impairment, ranging from:s of neurological impairment, ranging from:-- Limited mobility Limited mobility -- To total debilitationTo total debilitation


Stroke Survival and Recovery:Stroke Survival and Recovery:-- The goal is to begin therapy no longer than The goal is to begin therapy no longer than 60 minutes after the 60 minutes after the

arrival at the hospitalarrival at the hospital door and within door and within 3 hours of the initial onset3 hours of the initial onset-- This requires both preThis requires both pre--hospital and hospital providers to avoid delayshospital and hospital providers to avoid delays-- Pivotal points represent survival and recoveryPivotal points represent survival and recovery


Assessment:Assessment:-- After appropriate management of ABCAfter appropriate management of ABC’’s a rapid assessment of s a rapid assessment of

patient and a brief targeted history helps identify patientpatient and a brief targeted history helps identify patient’’s potential s potential for stroke enabling prompt treatmentfor stroke enabling prompt treatment

-- Warning Warning signs of acute ischaemic strokesigns of acute ischaemic stroke::-- ConfusionConfusion-- Slurred speechSlurred speech-- Unilateral facial droopUnilateral facial droop-- Unilateral weakness or paralysisUnilateral weakness or paralysis

-- Particularly important to determine when symptoms beganParticularly important to determine when symptoms began-- If patient meets inclusion criteria fibrinolytic therapy can begIf patient meets inclusion criteria fibrinolytic therapy can beginin-- This must be accomplished This must be accomplished within 3 hours of onset of symptomswithin 3 hours of onset of symptoms


Cincinnati PreCincinnati Pre--Hospital Stroke Scale:Hospital Stroke Scale:-- Allows identification of possible strokeAllows identification of possible stroke-- Three tests, any abnormality in any one Three tests, any abnormality in any one –– STROKE suspectedSTROKE suspected

Case Review 8 Case Review 8 –– StrokeStrokeTreatment:Treatment:-- Mainly supportive and focuses on protecting the airway and Mainly supportive and focuses on protecting the airway and

delivering supplemental oxygendelivering supplemental oxygen-- Monitoring ECG and providing IV therapyMonitoring ECG and providing IV therapy-- Promptly transporting patient to facility that specialises in stPromptly transporting patient to facility that specialises in stroke care roke care

where fibrinolytic therapy can be initiated where fibrinolytic therapy can be initiated

Case Review 8 Case Review 8 –– StrokeStrokeFibrinolytic Therapy for Acute Ischaemic Stroke:Fibrinolytic Therapy for Acute Ischaemic Stroke:-- If within 3 hours of onset, and meets inclusion criteriaIf within 3 hours of onset, and meets inclusion criteria-- Fit the following criteria, therapy can commenceFit the following criteria, therapy can commence

Case Review 8 Case Review 8 –– StrokeStrokeSummary:Summary:-- Can be a catastrophic event that can leave the patient with Can be a catastrophic event that can leave the patient with

permanent disabilities ranging from mild neurologic deficits to permanent disabilities ranging from mild neurologic deficits to complete incapacitationcomplete incapacitation

-- All patients require supplemental oxygen, IV therapy, cardiac All patients require supplemental oxygen, IV therapy, cardiac monitoringmonitoring

-- After assessment act quickly to identify as a candidate for therAfter assessment act quickly to identify as a candidate for therapy apy and transfer for this critical interventionand transfer for this critical intervention


Case Review 9 Case Review 9 –– Ventricular FibrillationVentricular FibrillationIntroduction:Introduction:-- It is important to reiterate that for every minute in VIt is important to reiterate that for every minute in V--Fib and Fib and

Pulseless VPulseless V--TachTach persists the survivability is reduced by 10%persists the survivability is reduced by 10%-- The single most important treatment is immediate defibrillation,The single most important treatment is immediate defibrillation,

monophasic or biphasicmonophasic or biphasic

Case Review 9 Case Review 9 –– Ventricular FibrillationVentricular Fibrillation

Treatment of VTreatment of V--Fib or Pulseless VFib or Pulseless V--TachTach::

-- The clinician must be prepared to change the treatment on the baThe clinician must be prepared to change the treatment on the basis sis of the patientof the patient’’s clinical response to therapy.s clinical response to therapy.

-- Remember to circulate all drugs with effective CPR for 2 minutesRemember to circulate all drugs with effective CPR for 2 minutesfollowed by defibrillation in Vfollowed by defibrillation in V--Fib or pulseless VFib or pulseless V--TachTach persistspersists

-- Following defibrillation, immediately resume CPR and reassess inFollowing defibrillation, immediately resume CPR and reassess in 2 2 minutesminutes

Case Review 9 Case Review 9 –– Ventricular FibrillationVentricular FibrillationSummary:Summary:-- VV--Fib is most common initial dysrhythmia in cardiac arrest and if Fib is most common initial dysrhythmia in cardiac arrest and if not not

promptly treated will deteriorate to asystolepromptly treated will deteriorate to asystole-- Successful management requires rapid assessment to confirm Successful management requires rapid assessment to confirm

cardiac arrestcardiac arrest-- If witnessed begin CPR ASAPIf witnessed begin CPR ASAP-- If not witnessed perform CPR for 2 minutes and then apply cardiaIf not witnessed perform CPR for 2 minutes and then apply cardiac c

monitor and defibrillatemonitor and defibrillate-- Intubation, IVT and pharmacological interventions are mandatoryIntubation, IVT and pharmacological interventions are mandatory-- Patient should be defibrillated with once off 360J or biphasic Patient should be defibrillated with once off 360J or biphasic

equivalent then CPR for 2 minutes, reassess and defibrillate as equivalent then CPR for 2 minutes, reassess and defibrillate as requiredrequired


Case Review 10 Case Review 10 –– Wide Complex TachycardiaWide Complex Tachycardia’’ss

Introduction:Introduction:-- A wide complex tachycardia refers to a rhythm in which A wide complex tachycardia refers to a rhythm in which QRSQRS

complexes are complexes are greater than 0.12 secondsgreater than 0.12 seconds in width and ventricular in width and ventricular rate is rate is > 100bpm> 100bpm

-- Approximately Approximately 90%90% of wide complex tachycardiaof wide complex tachycardia’’s s are ventricular are ventricular tachycardiatachycardia, indicating rhythm originated from an , indicating rhythm originated from an ectopic pacemaker ectopic pacemaker in the ventriclesin the ventricles


Introduction:Introduction:


Treatment of Wide Complex TachycardiaTreatment of Wide Complex Tachycardia’’s:s:-- Careful and systematic assessmentCareful and systematic assessment

-- If patient not experiencing serious S & S, pharmacologic If patient not experiencing serious S & S, pharmacologic intervention, aimed at decreasing ventricular irritability, reduintervention, aimed at decreasing ventricular irritability, reducing cing tachycardiatachycardia

-- If serious symptoms linked to tachycardia, synchronised If serious symptoms linked to tachycardia, synchronised cardioversion needed without delaycardioversion needed without delay

-- High risk of deterioration to VHigh risk of deterioration to V--Fib, be prepared to defibrillate if Fib, be prepared to defibrillate if patient becomes pulselesspatient becomes pulseless


Antiarrhythmic Maintenance Infusions:Antiarrhythmic Maintenance Infusions:-- If terminated pharmacologically begin a maintenance infusion of If terminated pharmacologically begin a maintenance infusion of

antianti--arrhythmic agent that aided in the conversionarrhythmic agent that aided in the conversion

-- If synchronised cardioversion was used with no pharmacological If synchronised cardioversion was used with no pharmacological agent, give antiagent, give anti--arrhythmic bolus and commence maintenance arrhythmic bolus and commence maintenance infusioninfusion

-- Important to maintain therapeutic blood levels of antiImportant to maintain therapeutic blood levels of anti--arrhythmic arrhythmic agent because this will prevent the recurrence of the wide complagent because this will prevent the recurrence of the wide complex ex tachycardiatachycardia


Summary:Summary:-- If a patient presents with a wide complex tachycardia you must If a patient presents with a wide complex tachycardia you must

assume it is ventricular tachycardia until proven otherwiseassume it is ventricular tachycardia until proven otherwise-- Continuous monitoring of the patientContinuous monitoring of the patient-- VV--TachTach can rapidly deteriorate to Vcan rapidly deteriorate to V--FibFib-- Must have:Must have:

-- Supplemental oxygenSupplemental oxygen-- Cardiac monitoringCardiac monitoring-- IVTIVT-- 12 lead if available12 lead if available

-- Treatment is based on being unstable or stable in origin, therefTreatment is based on being unstable or stable in origin, therefore ore systematic and careful assessment needs to occur, rapidly to systematic and careful assessment needs to occur, rapidly to identify S & S associated with wide complex tachycardiaidentify S & S associated with wide complex tachycardia

QUESTIONS?QUESTIONS?

That now concludes the theory component of theThat now concludes the theory component of the““ADVANCED CARDIAC LIFE SUPPORTADVANCED CARDIAC LIFE SUPPORT””

Course.Course.

Australasian Emergency ResponseAustralasian Emergency ResponseSpecialists Specialists Pty LtdPty Ltd

TASMANIA & PNG

Thank you for your participation on behalf of Thank you for your participation on behalf of thethe…………..

“FAILURE TO PREPARE IS TO PREPARE TO FAIL”

Health & Medicine

Presentation e acls aremt