SAEDRecertification
Prepared by:
Program Co-ordinator:
Tim Dodd
Program Manager:
Ken Stuebing
Hamilton Health Sciences Base Hospital Program
Clinical Staff Medical Director
– Dr. Welsford Program Managers
– Steve Dewar– Ken Stuebing
Program Co-ordinator– Tim Dodd
Course Overview
Chain of Survival Pathophysiology Review
– Respiratory– Circulatory
Cardiac Monitoring Protocols Special Circumstances CPR & SAED Reminders
Chain of Survival Early Access (911)
– Someone must realize there is an emergency an act quickly to initiate the EMS.
Early CPR– A trained individual starts CPR at once to help
maintain a viable heart until help arrives. Early Defibrillation
– The first responder arrives with the training and equipment to defibrillate the heart. As time increases chances for survival decrease.
Early Advanced Life Support– ALS delivered within minutes also increases
the chance for survival.
Chain of Survival
RESPIRATORY SYSTEM
Respiratory SystemUPPER RESPIRATORY TRACT:Warms, Filters & Humidifies
»Nose / Mouth»Pharynx»Voice box
LOWER RESPIRATORY TRACT:Air Exchange
»Trachea»Bronchi»Bronchioles»Alveoli
LUNGSAir travels down the trachea until it enters alveoli.
GAS EXCHANGE ONLY HAPPENS IN THE
ALVEOLI!(STOP COMPRESSION &
give slow, gentle, deep breaths)
WHERETHE CIRCULATORY SYSTEM
ANDRESPIRATORY SYSTEM JOIN
How Air Enters The Lungs INSPIRATION:- Diaphram contracts. (drops)- Intercostal muscles contract.
(ribs go up & out)- Creates a negative pressure in the lungs (alveoli) in comparison to the atmosphere. - Atmospheric air rushes in to fill void. - Gas exchange occurs by diffusion.EXPIRATION:- Muscles relax Raises Pressure - Forces Air Out
QuickTime Movie
Oxygen Saturation
The paramedic will be able to initiate pulse oximetry monitoring and monitor the effectiveness of the patient’s respiratory status and treat to ensure that adequate and effective oxygenation is maintained.
How can the monitor be fooled?
Factors Affecting Oximetry Strong ambient light sources Poor circulation Cardiac arrest Hypothermia Shock Anemia CO poisoning Nail polish
Oxyhemaglobin Disassociation Curve
Take Home Points Oxygen saturation measurement may
be utilized to monitor a patient’s condition but should not be used to make decisions to restrict oxygen delivery when the patient appears ill or has a condition that may require supplemental oxygen.
Remember to treat the patient not the monitor. If the patient appears ill and you feel oxygen will benefit the patient, give oxygen! - it grows on trees.
Circulatory System
Expectation of the PCPKnowledge of Circulatory System
components (Pipes, Pump & Fluid)Knowledge of: heart conduction and
it’s relation to specific ECG waves as well as how these waves are related mechanically to the heart muscle
Specific rhythms
– NSR, VF, VT, PVC’s, Asystole, PEA, Artifact, Paced Beats.
The Heart (pump)
Echocardiography
Heart Valve Replacement
Blood Vessels - Pipes Arteries:
– carry blood away from the heart.– thick muscular walls. (3 layers)
Veins:– bring blood back to the heart.– thinner walls. (3 layers)
– have valves to stop back flow.– Is the spare blood reservoir.
Capillaries: 1 cell thick. (tissue paper)
– join arteries and veins together.– wraps cell & alveoli.– where diffusion takes place.
Blood Vessel Diseases Arteriosclerosis
– host of diseases which cause thickening & hardening of arterial walls.
– Plaque formation, calcium build up & occlusion of small branching blood vessels.
– Clots can dislodge and occlude smaller vessels.
Aneurysm– weakened area in the wall of
an artery will tend to balloon out & may burst.
Atherosclerosis
Angiogram
Angioplasty
Blood - Fluid Consists of:
– Red Blood Cells (RBC): which carries the oxygen from the lungs to the cells and carbon dioxide from the cells to the lungs.
– White Blood Cells (WBC): which is part of our immune system to fight against infection.
Blood - Fluid Consists of:
– Platelets: form the base for clots.– Plasma: water component which carries all
these components.– Clotting Factors: 12 factors which work in
a complicated cascade to form a clot. All 12 are needed and stored blood does not cave all 12.
Any factor affecting the ability of blood to carry oxygen to the heart and brain can cause tissue damage.
M.I. – Myocardial Infarction muscle / heart death
M.I. = death of the heart muscle
Death of the muscle is due to starvation of oxygen & nutrients.
Other causes . . .– disruption of blood
supply– blockage of a coronary
artery, aneurysm– asphyxiation– e.t.c.
Angina Pectoris Angina pain is caused
by an inadequate oxygen supply to heart.
Supply and demand– spasm, inability to open.
• stress, cold, MVO2. Pain is similar to that of
an MI– is usually relieved by:
rest, nitroglycerin, oxygen
STROKE or CVA CVA - Is very similar to an
MI, - irreversible damage is done to the brain by lack of blood supply.
Tissue death results from starvation of oxygen and nutrients.
Disruption of blood supply:– blockage of a cerebral
artery, aneurysm– asphyxiation,
strangulation– heart attack, e.t.c.
STROKE Oxygen and nutrients are
supplied to the brain by two arterial systems– carotid - left and right– vertebral - left and right
Blood is returned from the brain via two large veins (left and right jugulars)
Brain receives 20% of CO A Stroke occurs when the
brain is deprived of oxygen
Take Home Points
Stop compressions and allow time for diffusion of gasses.
Remember not all cardiac pain is the same.
If you are at risk for heart attacks you are at risk for stroke– a new stroke campaign is about to start in
our area
Cardiac Monitoring
Normal Electrical Conduction
Electrocardiogram
Dysrhythmia Interpretation: 5 Steps Approach Step 1: What is the rate?
– bradycardia < 60 bpm– tachycardia > 100 bpm
Step 2: Is the rhythm regular or irregular? Step 3: Is there a P wave - is it normal?
– are P waves associated with each QRS? Step 4: P-R Interval/relationship?
– PR interval (normal .12 - .20 sec) Step 5: Normal QRS complex?
– Normal QRS complex < .12sec
Lethal Dysrhythmias
There are four major life threatening Pulseless Dysrhythmias:– NON SHOCKABLE RYTHMS
1) Asystole - Flat Line
2) PEA - Pulseless Electrical Activity– SHOCKABLE RHYTHMS
3) VF - Ventricular Fibrillation
4) VT - Pulseless Ventricular Tachycardia
Asystole
No heart electrical activity
No excitation of the heart muscle
No Cardiac output
Normal Sinus Rhythm
Regular heart electrical conduction
Heart Rate avg. 72 beats / minute
Normal Cardiac Output
Pulseless Electrical Activity PEA is an electrical disturbance in
which an electrical stimulus is being generated but the muscle is NOT reacting.
DO NOT assume that since there is a rhythm on the screen that the patient has a pulse!!
Ventricular Tachycardia
Stimulus is originating from the ventricles
Heart (pump) is cavitating by beating too fast
Poor cardiac output, but may produce a pulse
The SAED will shock V.T. with-in preset limits.
Ventricular Fibrillation
No organized excitation of heart muscle
Heart is physically quivering compared to contracting (seizing)
No Cardiac Output
Chances of survival decline ~ 7 to 10 % for every minute that
defibrillation is delayed.
Defibrillation Defibrillation applies electrical energy
to the heart muscle This energy causes depolarization of
all heart cells at the same time. Therefore all repolarize at the same
time. We hope this starts an organized
perfusing rhythm We only apply a shock, via the
S.A.E.D, to the heart of a VSA patient
Other Rhythms
Step 1: Rate? Step 2: Regular or irregular? Step 3: Is the P wave normal?
Step 4: P-R Interval/relationship? Step 5: QRS complex < 0.12 sec?
~ 90 bpm
Irregular
P waves normal, extra beats haveassociated P wave
0.12 - 0.20 secYes
PACs
Step 1: Rate? Step 2: Regular or irregular? Step 3: Is the P wave normal? Step 4: P-R Interval/relationship? Step 5: QRS complex < 0.12 sec?
Variable < 100
Irregularly IrregularNo P waves
None
Yes
Atrial Fibrillation
Step 1: Rate? Step 2: Regular or irregular? Step 3: Is the P wave normal?
Step 4: P-R Interval/relationship? Step 5: QRS complex < 0.12 sec?
A = 300 bpmV = 75 - 150 bpm
Irregular -VariableSawtooth P waves - March through QRS
NA
Yes
Atrial Flutter
Step 1: Rate? Step 2: Regular or irregular? Step 3: Is the P wave normal?
Step 4: P-R Interval/relationship? Step 5: QRS complex < 0.12 sec?
Variable ~ 100
Irregular
P waves Associatedwith most QRS
Yes - not allYes - but not all
PVC - unifocal
Step 1: Rate? Step 2: Regular or irregular? Step 3: Is the P wave normal?
Step 4: P-R Interval/relationship? Step 5: QRS complex < 0.12 sec?
150
Regular
No P waves
NA
Yes
Accelerated Junctional
Step 1: Rate? Step 2: Regular or irregular? Step 3: Is the P wave normal?
Step 4: P-R Interval/relationship? Step 5: QRS complex < 0.12 sec?
40-70
Irregular
P waves regularNot always with a
QRS
longer each beat
Yes
Second Degree AV Block Type 1
Step 1: Rate? Step 2: Regular or irregular? Step 3: Is the P wave normal?
Step 4: P-R Interval/relationship? Step 5: QRS complex < 0.12 sec?
< 30 bpm
RegularP waves normal,
not associatedwith all QRS
None
Yes3rd degree Heart Block
Cardiac Monitoring and
Lead Placement3 & 5 Lead
RA (White): Place near right mid-clavicular line, directly below the clavicle.
LA (Black): Place near left mid-clavicular line, directly below the clavicle
LL (Red):Place between 6th & 7th
intercostal Space on left mid-clavicular line
RL (Green): Place between 6th and 7th intercostal Spac on right mid-clavicular line
V (Brown): Place to Right of sternum at the 4th
intercostal Space
Electrode Placement
BIPOLAR Leads or LIMB Leads (I,II,III)
BiPolar Leads I, II &III
Lead II
Lead III
Lead I
Take Home Points
Use the 5 step approach.– Remember where the lead is and what it
should look like. (lead placement can effect what you see)
– Use it or lose it. Remember Normal electrical
conduction path and rates. The monitor is a voltage gauge not a
pressure gauge - check the Pulse!
Protocols
Medical Protocol Completion
9 S H O C KS T O T AL 3 N O S H O C K SIN A R O W
R E T U R N O F A P U L SE
M ed ica l P ro to col w illE N D O N E O F T H R E E W A Y S
Guidelines 10 second pause between shock and
subsequent analysis to prevent accidentally missing a shockable rhythm
If Protocol ends with 3 “No Shocks” in a row If you receive:
• 3 “Check Patient” messages in a• 2 minute time frame • STOP the vehicle and Analyze• Result in:
–1 No Shock
–1 Stack of 3 Shocks
• Transport
3 2 1 Go
Hypothermia Cardiac Arrest
1 NO SHOCK
ANYWHERE
– Check pulse No Pulse
– CPR concurrent with transport
3 SHOCKS TOTAL– Shock #1– Shock #2– Shock #3– Check Pulse
No Pulse– CPR transport
Blunt Trauma Protocol
This protocol does not include VSA patients as a result of penetrating trauma.
After adequate airway and c-spine management, apply AED and proceed with the following algorithm if Blunt Trauma is the suspected cause of the arrest.
Blunt Trauma Protocol 1 NO SHOCK
ANYWHERE– Check pulse– No Pulse CPR
concurrent with BTLS care
– Transport
3 SHOCKS TOTAL– Shock #1– Shock #2– Shock #3– Check pulse– No Pulse CPR
concurrent with BTLS care
– Transport
Airway Obstruction 1 NO SHOCK
ANYWHERE– Check pulse– No Pulse– CPR– Transport
3 SHOCKS TOTAL– Shock #1– Shock #2– Shock #3– Check pulse– No Pulse– CPR– Transport
Ventilate - Reposition - VentilatePerform visualisation of airway q 15 compressions
If cleared start protocol minus shocks delivered
Pulse Checks The defibrillator/monitor is a voltage meter
not a pressure gauge. It does not tell you if the patient has a pulse; it
is the operators responsibility to ensure the pulse is absent - it will defibrillate V-Tach >180 with a pulse into asystole!
Defibrillator pads are attached only to pulseless patients
Do not assume the patient has a pulse with the appearance of spontaneous respiration's
Defibrillator Errors If the defibrillator fails during a call,
complete the following actions. – Check the adherence of the pads;change
pads if required– Check the cables and connections– Change the battery– ALL these actions should take no longer
than 60 seconds– If you cannot solve the problem, abandon
the protocol and continue with BCLS only
Unusual Occurrences
Vomiting patient during charge up Pacemakers Automatic Implantable Cardioverter
Defibrillator(AICD) DNR orders
– unless the patient falls under the MOH Interfacility DNR directive, DNR orders will NOT be recognised in the field
When is the Defibrillator not attached to a VSA patient?
Age < 8 years old (new) Penetrating trauma Obviously Dead
Take Home Points
Complete one minute of CPR Initiate the appropriate protocol Complete the appropriate protocol Keep track of how many “No Shock
advised” in a row
CARDIOPULMONARY RESUSCITATIION
CPR
Role of CPR Integral component
of AED use CPR circulates
oxygen...– Prolongs heart’s
electrical activity– Minimizes brain
damage ...but defibrillation is
the definitive treatment
AdultCompression / Ventilation
Ratios 1 Rescuer:15:2
– 2 Rescuer: 15:2
Once airway is protected (ie. Intubated)
5:1 Ratio - pause compressions for ventilations to allow time for diffusion of gases!
Compressions Rates
Adult rate: 80-100 per minute Child rate: 100 per minute Infant rate: > 100 per minute Two Thumb method used for
infant compressions
QUESTIONS?