Algorithms Bradycardia with a Pulse Stable Cardiopulmonary status Cardiopulmonary Compromise ...
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REVIEW OF PALS ALGORITHMS
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Algorithms Bradycardia with a Pulse
Stable Cardiopulmonary statusCardiopulmonary Compromise
Tachycardia with Pulses and Poor PerfusionSinus TachycardiaSupraventricular TachycardiaVentricular Tachycardia
Pulseless ArrestVentricular Fibrillation vs. Ventricular TachycardiaAsystole vs. PEA
Septic Shock
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Steps involved when called to evaluate a patient Help can be called for at any time!!! The sooner the better! #1
LOOK AT YOUR PATIENT!! Sick or not sick
#2 Examine
#3 Cardiac Monitor
#4 Check wires/tubing
#5 Call for help and Establish Roles
#6 Identify Algorithm
#7 Resuscitation Supplies/Meds
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Sick or Not Sick?
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Sick or Not Sick
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Sick or Not Sick
http://www.youtube.com/watch?v=XJ-ON24aO9s&feature=BFa&list=PLF7E5E6EAB1933606
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Examine
Get history (RN/family concerns, HPI, hospital course)
Vital signs (trends and current) Physical Exam (ABC’s)
AirwayBreathingCardiovascular
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Physical Exam
AirwayCan patient speak or cry?Look: for respiratory distress (i.e. grunting,
flaring retractions), choking, cyanosisListen: air movement in neck and chest,
quality (stridor, wheeze, etc..), I:E, RRFeel: movement from mouth, nose, chest
rise, crepitusAssess: can airway be maintained with
basic maneuvers/positioning, suction
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Physical Exam Breathing
Is patient moving sufficient air in and out to maintain effective oxygenation and ventilation?
Look: RR, trachea position, symmetry of chest rise, accessory muscles, skin color
Listen: symmetry and quality, adequacy of air movement, intrathoracic sounds (stridor, crackles, wheeze)
Feel: subcutaneous air, tenderness, instability of chest wall
Assess: stable or not? Respiratory failure? BMV? Intubate? Trumpets?
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Physical Exam Cardiovascular
Adequate circulation to support end-organ function?Look:
○ poor perfusion: cyanosis, mottling, pallor, altered mental status
○ Chest trauma: asymmetry of chest expansion○ Jugular Venous Distention
Listen○ Heart rate: tachycardic vs. bradycardic vs. normal○ Heart tones: murmur, rub, gallop○ Breath sounds: rales vs. wheeze○ Diminished Breath sounds
Feel○ Central pulses, temperature of skin, capillary refill
Assess○ Adequate vs. inadequate vs. absent
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Cardiac Monitor Know what the numbers on the monitor mean Make sure connections are correct and
wires/leads actually attached to the patientLead placement: White is right, Smoke (black)
over fire (red)WaveformHeart rate from leads and pulse oximeter should
correlate If patient on oxygen, make sure connected
appropriately to wall with no kinks and cannula/mask placed appropriately
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Establish Roles
Code TeamTeam LeaderAirway PhysicianFloat PhysicianMedication NurseBedside NurseCirculating NurseDocumenterAssistants
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Identify Algorithm
Pulse vs. No Pulse
Pulse No Pulse
Shockable
Ventricular Fibrillation
Ventricular Tachycardia
Not Shockable
AsystolePulseless Electrical Activity
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What makes a Rhythm Shockable? The heart is active, but in a life-threatening
and dysfunctional pattern. In Ventricular Tachycardia, the heart is unable to pump blood effectively as it is beating too quickly to fill. This will ultimately lead to ventricular fibrillation. At this point the electrical activity in the heart becomes chaotic – again preventing the heart from pumping effectively. Over time, the fibrillation will decrease and the heart will become asystolic from lack of appropriate oxygenation.
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What makes a Rhythm Shockable? Defibrillation – for UNORGANIZED
rhythmsTherapeutic delivery of an unsynchronized
electrical current through the myocardium over a brief period to terminate the dysrhythmia
Does not jump start the heartPurpose is to depolarize the ventricular cells
simultaneously (including fibrillating cells) asystole natural pacemakers will resume normal activity
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What makes a Rhythm Shockable? Synchronized Cardioversion – for
ORGANIZEDDelivery of a shock to the heart to terminate
a rapid dysrhythmia that is times to avoid vulnerable periods in the cardiac cycle (peak to end of T wave)
Heart cells will contract simultaneously interrupting and terminating the abnormal electrical rhythm without damaging the heart allowing the sinus node to resume normal pacemaker activity
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Identify AlgorithmPulse vs. No
Pulse
Bradycardia
Cardiopulmonary system stable?
Yes
ABC’s
Compromise
CPR
Tachycardia
Pulse
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Identify AlgorithmPulse vs. No
Pulse
Bradycardia Tachycardia
Narrow QRS (<.0.8 seconds)
Sinus Tachycardia
Supraventricular Tachycardia
Wide QRS (>0.08 seconds)
Ventricular Tachycardia
Pulse
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Rhythms
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Rhythm
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Rhythm
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Rhythm
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Rhythm
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Rhythm