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© 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!
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Cisco ERT Cardiac Emergency Brownbag

Nov 02, 2014

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Health & Medicine

Rakesh Bharania

Cardiac Emergencies Brownbag as delivered to the Cisco ERT
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Page 1: Cisco ERT Cardiac Emergency Brownbag

© 2006 Cisco Systems, Inc. All rights reserved. Cisco PublicPresentation_ID 1

Cardiac Emergencies &Oxygen AssistanceRakesh Bharania, EMT-B

We gotta go to Cisco … again!

Page 2: Cisco ERT Cardiac Emergency Brownbag

© 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

Page 3: Cisco ERT Cardiac Emergency Brownbag

© 2006 Cisco Systems, Inc. All rights reserved. Cisco PublicPresentation_ID 3

The Key To Survival

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© 2006 Cisco Systems, Inc. All rights reserved. Cisco PublicPresentation_ID 4

Cardiac Chain Of Survival

But all this starts with you

Early911

EarlyCPR

EarlyDefibrillation

EarlyAdvanced

Care

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© 2006 Cisco Systems, Inc. All rights reserved. Cisco PublicPresentation_ID 5

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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© 2006 Cisco Systems, Inc. All rights reserved. Cisco PublicPresentation_ID 6

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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© 2006 Cisco Systems, Inc. All rights reserved. Cisco PublicPresentation_ID 7

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)

© 2006 Cisco Systems, Inc. All rights reserved. Cisco ConfidentialPresentation_ID 7

Page 8: Cisco ERT Cardiac Emergency Brownbag

© 2006 Cisco Systems, Inc. All rights reserved. Cisco PublicPresentation_ID 8

The Heart

Page 9: Cisco ERT Cardiac Emergency Brownbag

© 2006 Cisco Systems, Inc. All rights reserved. Cisco PublicPresentation_ID 9

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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© 2006 Cisco Systems, Inc. All rights reserved. Cisco PublicPresentation_ID 10

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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© 2006 Cisco Systems, Inc. All rights reserved. Cisco PublicPresentation_ID 12

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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© 2006 Cisco Systems, Inc. All rights reserved. Cisco PublicPresentation_ID 13

Cardiac Emergencies

Page 14: Cisco ERT Cardiac Emergency Brownbag

© 2006 Cisco Systems, Inc. All rights reserved. Cisco PublicPresentation_ID 14

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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© 2006 Cisco Systems, Inc. All rights reserved. Cisco PublicPresentation_ID 16

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

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© 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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© 2006 Cisco Systems, Inc. All rights reserved. Cisco PublicPresentation_ID 18

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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© 2006 Cisco Systems, Inc. All rights reserved. Cisco PublicPresentation_ID 19

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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© 2006 Cisco Systems, Inc. All rights reserved. Cisco PublicPresentation_ID 20

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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© 2006 Cisco Systems, Inc. All rights reserved. Cisco PublicPresentation_ID 22

Ventricular Tachycardia

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© 2006 Cisco Systems, Inc. All rights reserved. Cisco PublicPresentation_ID 23

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

Page 24: Cisco ERT Cardiac Emergency Brownbag

© 2006 Cisco Systems, Inc. All rights reserved. Cisco PublicPresentation_ID 24

Defibrillation for Everyone!

Page 25: Cisco ERT Cardiac Emergency Brownbag

© 2006 Cisco Systems, Inc. All rights reserved. Cisco PublicPresentation_ID 25

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

Page 26: Cisco ERT Cardiac Emergency Brownbag

© 2006 Cisco Systems, Inc. All rights reserved. Cisco PublicPresentation_ID 26

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

Page 27: Cisco ERT Cardiac Emergency Brownbag

© 2006 Cisco Systems, Inc. All rights reserved. Cisco PublicPresentation_ID 27

Cardiac Science PowerHeartAED G3

Fully automated.

Biphasic, adjusts for patient

“Rescue Ready” indicator

Page 28: Cisco ERT Cardiac Emergency Brownbag

© 2006 Cisco Systems, Inc. All rights reserved. Cisco PublicPresentation_ID 28

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.

Page 29: Cisco ERT Cardiac Emergency Brownbag

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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!!!

Page 30: Cisco ERT Cardiac Emergency Brownbag

© 2006 Cisco Systems, Inc. All rights reserved. Cisco PublicPresentation_ID 30

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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© 2006 Cisco Systems, Inc. All rights reserved. Cisco PublicPresentation_ID 32

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

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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.

Page 34: Cisco ERT Cardiac Emergency Brownbag

© 2006 Cisco Systems, Inc. All rights reserved. Cisco PublicPresentation_ID 34

Oxygen Assistance

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© 2006 Cisco Systems, Inc. All rights reserved. Cisco PublicPresentation_ID 35

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)

Page 36: Cisco ERT Cardiac Emergency Brownbag

© 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.

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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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© 2006 Cisco Systems, Inc. All rights reserved. Cisco PublicPresentation_ID 38

PulsePoint

Location-aware public CPR/AED alert app for Apple iPhone & Android www.firedepartment.mobi

Page 39: Cisco ERT Cardiac Emergency Brownbag

© 2006 Cisco Systems, Inc. All rights reserved. Cisco PublicPresentation_ID 39

Now that we have AEDs & O2 how about a pony?