© 2006 Cisco Systems, Inc. All rights reserved.Cisco Public Presentation_I D 1 Cardiac Emergencies & Oxygen Assistance Rakesh Bharania, EMT-B We gotta go to Cisco … again!
Nov 02, 2014
© 2006 Cisco Systems, Inc. All rights reserved. Cisco PublicPresentation_ID 1
Cardiac Emergencies &Oxygen AssistanceRakesh Bharania, EMT-B
We gotta go to Cisco … again!
© 2006 Cisco Systems, Inc. All rights reserved. Cisco PublicPresentation_ID 2
Agenda
You Are Key!
Heart Overview
Cardiac Emergencies
ERT Cardiac protocols
Oxygen assistance
PulsePoint
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The Key To Survival
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Cardiac Chain Of Survival
But all this starts with you
Early911
EarlyCPR
EarlyDefibrillation
EarlyAdvanced
Care
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First responders make the difference!
Cisco ERT can be the difference between life and death in a cardiac emergency.
The numbers prove it.
Trained bystanders save as many people as ALS paramedics do, and send more home with intact brain function
Why? Time!
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Real-world examples
Seattle, WA: CPR training is widespread and EMS response and time to defibrillation is short, the survival rate for witnessed VFib cardiac arrest is about 30%.
New York City: few victims receive bystander CPR and time to EMS response and defibrillation is longer, survival from sudden VFib cardiac arrest averages 1–2%
Security guards at O’Hare Airport (Chicago), Las Vegas Casinos achieve a survival rate of 50-74%!
Since AED deployment, Cisco ERT has a 100% success rate (3 for 3)
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CPR and AED use is recommended for both traditional and non-traditional public safety responders - this is a Class I recommendation.
AED Programs should be implemented in sites where there is a high likelihood of witnessed cardiac arrest. - this is a Class I recommendation
2005 AHA CPR/ECC Guidelines (reaffirmed in 2010 CPR/ECC)
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The Heart
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Basic Anatomy
About the size of your fist
100k beats / day
2000 gal. blood pumped / day
Four chambers:> two atria (top)> two ventricles (bottom)
Four one-way valves:> Tricuspid> Pulmonary> Mitral> Aortic
Two coronary arteries supplythe heart muscle itself (not shown)
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The Heart’s Electrical System
The sinoatrial (SA) node is the heart’s “natural pacemaker”
Electrical impulses travel to the atrioventricular (AV)node.
Through the Bundle of His
Signal splits down the left and right bundlebranches
Normal adult rate: 60-100/min,can vary due to stress, physical activity, hormonal changes
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The Heartbeat - Diastole
Diastole – atria pumping
SA node sends an electrical signal – atrial contraction
Tricuspid and Mitral valvesopen, filling the ventricles
Pulmonary and Aortic valves areclosed
This is the longer of the two phases ofa heartbeat
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The Heartbeat - Systole
Systole – ventricles pumping
Electrical impulse arrives at the AV nodeand travels down to the two bundlebranches causing ventricular contraction
Pulmonary and Aortic valves areopened, blood forced out tothe lungs for oxygen, andto the rest of the body
Tricuspid and Mitral valvesclosed, preventing backflow
This is the shorter of the two phases ofa heartbeat
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Cardiac Emergencies
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Cardiac Emergencies
Heart disease the #1 cause of death for Americans.
We’ll talk about the most common cardiac emergencies you may be faced with.
> Heart Attacks> Sudden Cardiac Arrest
Remember: While not all chest pain/discomfort is cardiac, all chest pain calls should be treated as such!
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Heart Attacks
A heart attack (myocardialinfarction or MI) occurswhen the heart’s oxygensupply is blocked &heart muscle is damaged(infarction)
Caused by plaque buildupin the coronary arteries
When plaque ruptures, plateletsform clots around the plaque
This can restrict blood todistal portions of the heart
Drugs: asprin, thrombolytics“clot busters”, vasodilatorssuch as nitroglycerin
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Heart Attacks – Typical Signs/Symptoms
Chest discomfort. Most heart attacks involve discomfort in the center of the chest that lasts more than a few minutes, or that goes away and comes back. It can feel like uncomfortable pressure, squeezing, fullness or pain.
Discomfort in other areas of the upper body. Symptoms can include pain or discomfort in one or both arms, the back, neck, jaw or stomach.
Shortness of breath. This feeling often comes along with chest discomfort. But it can occur before the chest discomfort.
Other signs: These may include breaking out in a cold sweat, nausea or lightheadedness, denial
© 2006 Cisco Systems, Inc. All rights reserved. Cisco PublicPresentation_ID 17
Heart Attacks – Women
“Atypical presentations are typical for women.”
Chest pain is not as common a symptom of a heart attack in women as it is in men (43% reported no chest pain/pressure)
Women are more prone to experience so-called “atypical” symptoms than men before and during a heart attack
Such symptoms include (but are not limited to): Back, neck, or jaw pain
NauseaVomitingIndigestionWeaknessFatigueDizzinessLightheadedness
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Sudden Cardiac Arrest - Overview
Sudden Cardiac Arrest != Heart Attack.
SCA = electrical problem
MI = plumbing problem
It is the largest cause of natural death in the U.S., causing about250,000 adult deaths each year
SCA occurs most frequentlyin adults mid-30s to mid-40s, and affects men twice as often as it does women
We worry about two rhythms,ventricular tachycardia (VTach), andventricular fibrillation (VFib)
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Sudden Cardiac Arrest – Signs/Symptoms
Patients will suddenly lose consciousness, without any prior warning.
No breathing (there may be ineffective breathing motions, however – “agonal breathing” – does not count as breathing)
No pulse
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ECGs in one slide
Electrocardiograms (ECG/EKG) record electrical activity of the heart.
Does not automatically correspond to physical action of the heart. Normal Sinus Rhythm includes a P wave, a QRS Complex
and a T wave. P = current for atrial contraction QRS = current for ventricular
contraction T = ventricular repolarization
(atrial repolaraization is hiddenby QRS)
The ECG is so familiar to thegeneral population that it ispart of the logo of many medical organizations, representing the technical side of medicine
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Ventricular Tachycardia
Ventricular Tachycardia isa rapid ventricular rhythm
Heart rate 140-250 butineffective perfusion
Can degrade to VFib Treated with: Valsalva
maneuvers,anti-arrhythmic drugs(Rakesh’s favorite: adenosine), cardioversion
Pulseless VTach isshockable by an AED(not all VTach is pulseless)
Normal Sinus Rhythm
Two examples of VTach
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Ventricular Tachycardia
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Sudden Cardiac Arrest - VFib
Ventricular Fibrillation occurs when the heart’s electrical activity loses all coordination
Pulseless, no BP Respiration will
stop, unconsciousness willoccur
Asystole (and death) will result unless treated
This is the most common cardiac arrest rhythm
Normal Sinus Rhythm
Two examples of VFib
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Defibrillation for Everyone!
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Defibrillation Facts
90% of adults successfully resuscitated from non-traumatic cardiac arrest were in VFib
The success of defibrillation is directly related to the time to defibrillation
Chances of successful defibrillation of pulseless VTach or VFib is 70-80% at time zero. Each minute that passes, chances of successful defibrillation decreases between 2-10%
Ten minutes after the event, chances of survival is near zero
Defibrillation does not “restart” a stopped heart (asystole), regardless of what the movies show
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Medtronic Lifepak CR Plus AED
Fully automated.
Can detect shockable rhythms
Delivers a “biphasic” shock. Accommodates patientimpedance
Pads are compatible withMedtronic ALS ECG monitors
20 minutes ECG record time
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Cardiac Science PowerHeartAED G3
Fully automated.
Biphasic, adjusts for patient
“Rescue Ready” indicator
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Updated AHA AED Behavior
1 shock followed by immediate CPR
After two min. of CPR, second shock delivered if needed.
No more “stacked shocks.” Most biphasic AEDs convert Vf in one shock.
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So who’s got ‘em?
ERT Leads
Mobile SAS Officers/Supervisors and SAS Coordinators
Cisco NERV disaster response trucks
Wall mounted in EBC/CBC & Fitness Center Locations
Wall mounted, one unit per building (typically first floor breakroom)
Cisco RTP and SJ Saves!!!
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So what about CPR?
CPR supports the patient but cannot reverse cardiac arrest.
It’s still needed to buy the time between arrest onset and defibrillation.
So, it’s still important. AHA: Re-emphasis on CPR. (C-A-B)
CPR is a hard skill for even those who do it all the time (paramedics, ER doctors, etc.)
Chest compressions often done too shallowly. Rate at least 100/min, Push hard, push fast.
Done properly, cartilage damage or rib breaking is common
Chest compressions can be done w/o breaths if unwilling or able to perform them!
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Emergency Protocols
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ERT Chest Pain protocol
Ensure 911 / BSI / Scene Safety
Have someone retrieve AED
Position of comfort, reassure patient
Assess vital signs, SAMPLE &OPQRST history
Oxygen (if available, and trained to do so) @ 15 lpm/NRB (preferred) or 6 lpm/cannula
Aspirin if asked by 911 and readily available.(325 mg – 4 x 81mg baby aspirin, chewed)
Be prepared to initiate CPR / AEDif patient goes unresponsive
© 2006 Cisco Systems, Inc. All rights reserved. Cisco PublicPresentation_ID 33
ERT Cardiac Arrest Protocol
Ensure 911 / BSI / Scene Safety
Have someone retrieve AED
Confirm unresponsiveness“Are you OK?”
If there is no breathing or onlyagonal breathing, immediately give 30 compressions. Rate = 100/min
Open airway (head-tilt, chin lift)and deliver two rescue breaths.
Perform CPR cycles of 30:2 until AED or EMS
If CPR in progress, 3rd person can setup & attach pads.
Deliver AED shock as soon as possible.
Recheck for breathing after every five cycles of CPR. Continueif needed.
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Oxygen Assistance
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Oxygen Assistance
Without a “patent” airway, regardless of any other emergency, the patient will not survive.
Cisco ERT Protocol (2011): Non-EMT ERT members may assist an oxygen-equipped ERT member with Oxygen
What this means: YOU can setup oxygen foran ERT EMT, but you cannot actually applythe oxygen to a patient.
OXYGEN SAFETY:
No smoking
Contents under pressure (don’topen w/o a regulator on the tank)
© 2006 Cisco Systems, Inc. All rights reserved. Cisco PublicPresentation_ID 36
Oxygen Delivery
Room air – 21% Oxygen however, we can deliver higher levels of oxygen when required…
Non-Rebreather Mask (NRB) – 60-100% Oxygen at 10-15 lpm. Preferred method of O2 delivery pre-hospital. Used on distressed or other serious patients.
Nasal Cannula – 24-44% Oxygen at 1-6 lpm. Common for long term O2 therapy, but not really good for pre-hospital. Used when patient won’t tolerate NRB or as a comfort measure.
Bag-Valve Mask – assists a patient who is breathing too slowly or not at all. Can be connected toO2 @ 15 lpm, 100% O2 delivery. Best used withan airway adjunct. Preferred over a pocket-mask
Oxygen Bear – provides “blow-by” oxygen forpediatric patients who won’t tolerate mask.
© 2006 Cisco Systems, Inc. All rights reserved. Cisco PublicPresentation_ID 37
Airway Adjuncts
If a patient is unable to manage their own airway due to altered mental status, trauma, etc. Trained persons (EMTs, etc.) are permitted to use two different types of “airway adjuncts” to help manage a patient’s airway.
Oropharyngeal Airways (OPA) are “hook-like” devicesthat are inserted into a person’s mouth to keep the tongue and epiglottis clear. Can only be usedon patients without a gag-reflex.
Nasopharyngeal Airways (NPA) are trumpet-like tubesthat are inserted into one of a patient’s nostrils. Canbe used on conscious or semi-conscious patients.
Each adjunct has its primary uses and contraindications.
Neither is considered a “definitive” airway – patientcould still aspirate. Intubation “secures” the airway,but is a paramedic skill.
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PulsePoint
Location-aware public CPR/AED alert app for Apple iPhone & Android www.firedepartment.mobi
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Now that we have AEDs & O2 how about a pony?