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Basic life support (BLS)

The goals of resuscitation interventions for patient in

respiratory or cardiac arrest to restore and support

effective oxygenation, ventilation, circulation with returnimpact neural functions.

Classification and recommendation and level of evidence

1.Class 1(benefits>>>risks): the procedure, treatment,

diagnostic test and assessment should be performed and

administered.

2.Class 2A (benefits>>risks): it is reasonable to perform and

administered procedure, assessment, diagnostic test, andtreatment.

3.Class 2B (benefits>= risks): the procedure and treatment,

assessment, and diagnostic test may be considered

4.Class 3 (risks>= benefits) : should not perform or

administer treatment, assessment and procedure..

Classification of survey:

1.Primary survey : include basic life support(BLS)

2.secondary survey: advance cardiac life support(ACLS)

The BLS primary survey

performed by any trained health care providers

without advanced interventions and depend on basic

ABCD

before contact of BLS should check the responsive of the

victims, activation EMS and get AED

health care provider should assess breathing before get

rescue breathing with mask

health care provider should assess pulse before initiate

chest compression

health care provider should assess shockable rhythm

before initiate DC shock

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Open airway by non invasive method (head tilt and chain

left) if patient with neck and head trauma thrust the jaw

without extension the head

Basic primary survey includes:

1)A(airway)

Open airway by non invasive method (head tilt and

chain left) if patient with neck and head trauma thrust

the jaw without extension the head

2)B(breathing)

Look, listen, feel if victims breathing or not, adequate

breathing or not If patient breath put he\she in recovery position

If victims absent breathing give two rescue breathing

each breath in one second and must observe it is rises the

chest

Do not ventilate fast(rate) or much(volume) to prevent

hyperventilation

3)C(circulations) Palpate in adult if carotid pulses are present or not by

apply three fingers on carotid artery in the groove area

behind the sternomastoid muscles, check should for 5

second and no more then 10 second and unilateral check.

Palpate in infant brachial or femoral pulses

If no pulses in adult or infant pulse less then 60

beat\min initiate chest compression with adult 30:2 and

infant with one rescuer 30:2 or 15:2 if have 2 rescuer Push hard, push fat 100 beat\min( in five cycle 150:10

in two minute)

Site of chest compression in adult between nipple in

below half of sternum and infant below the nipple level

Chest compression method: in adult put on heal of the

hand in the site of chest compression and other hand on

it. In infant used two thump and both adult and infant

make 1\4 depth or 3-5cm.

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During chest compression should avoid any

interruptions as check pulse, analysis rhythm, airway

management and switching the rescuer all of these aspect

done after 5 cycle or 2 min to provide adequate level of

circulation blood and oxygenation to brain and vital

organs

If pulses is present and absent breathing give adult 1

breath in 5-6 second and 1 breath in 3-5 second in infant

and check pulses every 2 minute

4)D(defibrillation)

If patient with shockable rhythm initiate and prepare

DC shock

Each DC shock or cardioversion must initiate CPR 5

cycle or 2 minute

Recovery positions

Recover position important in victims because it is

provide airway open, remove fluid in the mouth of

victims

This position called lateral position, and provide spinstraight, and put hand in position that maintain any chest

compression

1.during responsive victims

In adult

ask victims is shocking

give abdominal thrust (epigastrial thump) or chest thrust

if obese or pregnant victims

repeat technique until obstruction remove or victims

become un responsive

In infant

confirm infant difficult of breathing, silent cough,

cyanosis

give 5 back slaps and 5 chest thrust until remove

obstruction or victims become unresponsive

2.during unresponsive victims

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begin CPR in 5 cycles or 2 minute and look in mouth if

big foreign body causes obstruction and able to remove

it

ACLS secondary survey

1)A(airway)

Observe airway is patent and find indication of invasive

airway devices used

Maintain airway patent in unconscious patient by

noninvasive (head tilt and left chain) and invasive airway

as OPA (oropharyngeal airway) or NPA (nasopharyngeal

airway)Used laryngeal mask airway(LMA) or combitube or ETT

2)B(berating)

Observe: oxygen is adequate or not, proper placement of

airway devices, are exhaled CO2 or oxyhemoglobin

saturated.

Assessment adequate oxygenation depend on chest rises

during ventilation, oxygen saturation, capnometry orcapnography

Confirmation of airway placement through : physical

examination(5 point air entry, measure CO2 exhaled,

esophageal detector devices.

3)C(circulation)

Obtain IV, IO and attached monitors leads to analyze

rhythm , heart rateGive drug and fluid

Observe BP and take blood sample, cross matching

4)Defibrillations

Give patient DC or cardioversion is the rhythm is

shockable rhythm

5)Assess 6 H's and 6 T's

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H's: hypoxia, hypovolemia, hydrogen (acidosis),

hypo\hyper kalmeia, hypoglycemia, and hypothermia.

T's: toxin, tamponade(cardiac), tension( pneumothorax),

thrombosis, and trauma6)Assessment of disability

Assess GCS , mental status

Assess extremities injuries, excessive bleeding

Insert Foleys catheters and gastric tube

CODE of CPR

Role of team member:

1)Organize the group

2)Monitor individual performance of team member

3)Provide excellent team behaviors

4)Train and coach

5)Facilities and understanding all algorithms

6)Focus in competence patient care

Role of team member

1)Clear about role and take fulfill responsibilities about

her\his tasks

2)Well practiced in resuscitation skill and knowledgeable

about algorithm

3)Committed to success

Element of effective resuscitation team dynamics

1)Used close loop communications

Team leader give massage\order and assignment good

eye contact with team member

Team leader confirm order and the team member

confirm this order before done by repeat the order and

after the procedure done by say the procedure done, or

the drug given

2)Used clear massages

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All order which delivered by team leader must clear in

calm manner without shouting or yielding and speak

complete sentences

Team member repeat order before done and after doneclearly

3)Clear role and responsibilities

Each person must know her\his responsibilities to

prevent take many manner for one team member,

missing the primary role of team member, freelancing

one of team member

Team leader must clearly identify each team member

roleTeam member must ask if any difficult in her\his task

4)Know one's limitations

The team leader should be aware of limitation of each

team member

The leader should not practiced the team member for

new task during CPR to prevent any negative effect

Team member should not take new task during CPR

5)Knowledge sharing6)Constrictive intervention

Team leader must intervenes the actions in tactfully

manner

Team leader should not confront any team member and

after CPR criticism him

Team leader can suggest alternative drugs, and ask

about who is responsible of mistakes

7)Relevance of summarizingThe leader to reevaluate the patient status, make

massages friendly, and provide deferential diagnosis

8)Mutual respect

All team leader and team member must leave Ego

regardless any additional training or experienced that

the team leader or team member experienced or have it.

Leader speak friendly, and controlled of tone voice and

avoid shouting

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ACLS cases

Respiratory arrest

Respiratory arrest: complete absent or clearly inadequate

respiration to maintain effective oxygenation and

ventilations associated with present pulses

When patient com with respiratory arrest do the followingAsk the patient are you all right

Activate emergency responses 911 or AED

Patient with asphyxia arrest must do 5 cycle CPR then

contact with emergency responses

Initiate BLS

Patient with respiratory arrest give 1 oxygenation every

5-6 second but patient with respiratory arrest give 1

breath every 10-12 sec

Then check pulses in both cases after 2 minute

Increase rate (amount) of oxygenation or increase volume

lead to increase intra thoracic pressure (decrease venous

return and decrease CO), increase gastric inflation,

patient aspiration

Advance airway management:

Include 6 criteria:1. given and supply oxygen saturation 90%

2. open airway

3. provide basic ventilation management

4. used OPA or NPA management

5. suctions

6. provide ventilation with advance airway management

Opening airway

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Upper airway obstruction caused by loss of throat

muscles weakness or tongue fall back and occluded the

airway

Airway open by head tilt and chin left or jaw thrustwithout head extension if trauma occurs

Unconscious patient (no gag reflex, no cough) can

placement OPA or NPA to maintain airway potency

Is you seen foreign body obstruction airway able by used

finger to remove this foreign body

Basic air way management:

Various devices supplementary oxygen 21-100%

Divided to two type

1.non invasive : as oxygen supply cylinder, nasal

canula, face mask, ventori mask

2.invasive as OPA, NPA

Nasal canula:

low flow rate oxygenation provide oxygen up to 44% put

in patient nose

ratio describe as increase 1L\min increase concentration4% start at 1l\min maintain oxygen saturation 21-24%

1 L\min 2 L\min 3L\min 4L\min 5L\min 6L\min

12-24% 25-28% 29-32% 33-36% 37-40% 41-44%

Face mask

low rate oxygenation put in patient nose and mouth with

reservoir bag or without reservoir bag

with reservoir bag used when1. patient seriously ill and require high oxygenation

concentration

2. avoid ETT in acute intervention as pulmonary edema,

COPD , acute asthma

3. have indication of ETT but have high gag reflex , or

high clenched teeth

in case of high clenched teeth can used tight fitting mask

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Face mask supplement 60% oxygen concentration in flow

rate 6L\min(with ratio 1 L\min increase concentration

10%

6L\min 7 L\min 8 L\min 9L\min 10L\min

60% 70% 80% 90% 95-100

Ventori mask

More controlled of oxygenation delivery from 24-50%

concentration used for patient with COPD or chronic

increase CO2 level with sever hypoxemia

4-8L\min 10-12L-min

24-40% 40-50%

Bag mask ventilation

Consist of self inflating bag and non rebreathing valve

used when connect with advance airway tube or face

mask to provide positive ventilation pressure

Used of bag mask ventilations without advance airway

tube causes gastric inflations

Bag mask procedure1. fix on face and press against face

2. provide head tilt

3. mouth to mask ventilation (make C shape of thump

and index of one of your hand and press on mask )

Oropharyngeal airway(J shape)

used to prevent airway obstructions by the tongue and

facilitate suctioning used for unconscious patient after head tilt chain left or

thrust the jaw

should not used for conscious patient because it is

stimulate gag reflex and vomiting

technique of OPA insertion:

clear mouth and pharynx form secretions

select the size of the OPA by put the tip of airway on

the corner of the mouth and must reach the angle ofmandible and when you insert it must glottis opening

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insert airway that is turned backward then after

inserted rotate it 180 degree or same shape insertion by

used tongue blade

Nasopharyngeal airway

used when conscious or semiconscious patient or patient

with trauma in mouth or high gag reflex or cough

select the size and used lubricants

insert gently to prevent lacerate the adenoid tissue and

causes bleeding and aspiration

Advance airway management

Combitube

Alternative tube to provide adequate oxygenation and

have fetal risk complications

Consist of two inflatable tube(100cc and 15 cc) balloon

cuff and blind insertion without visualized vocal cord

(inserted in esophagus and trachea)

Laryngeal mask airway (LMA)

Composed of tube with cuffed mask , blind insertion untilfeel resistance

Not used for patient with regurgitation or aspiration

(class 3 survey)

Endotracheal tube (ETT)

during ETT insertion for patient without gagreflex or

cough or unconscious patient ask other team member to

cricoids pressure

Cricoids pressure maintain gastric regurgitation andfacilitate insertion of ETT, when pressure in cricoids used

thump and index fingers

Cricoids : the first prominent below thyroid cartilaginous

(Adam's apple)

Importance of ETT:

1. keep airway opening and deliver high oxygen rate

2. protect aspiration

3. facilitate suctioning

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4. alternate for medication if IV or IO impossible

indication of ETT

1. cardiac arrest and bag mask ineffective

2. responses patient but unable to oxygenation

3. patient unable to protect airway(coma, cardiac arrest

ETT medication administration protocol

1. Medication given to patient by ETT is: atropine,

vasopressin, epinephrine, and lidocain.

2. ETT medication must mixed with 10 cc saline or distal

water (saline increase liability absorption in airway

especially atropine drugs)

3. The dose of ETT medication high dose than IV or IO

equal 2-2.5*(IV or IO dose).

4. after ETT medication given 2 ventilation must be

performed to facilitate absorptions

Complication of ETT

If ETT insertion in esophagus causes patient suffer to brain

death and die

Confirmation of ETT

1. listen to the 5 point (2 apex, 2 base of the lung,epigastric region) associated with bag mask deliver

oxygenation

2. observe chest wall rises

3. gastric sound: gargling sound indicate of the ETT in

esophagus exhaled CO2 detectors devices

Purpose of defibrillations : to return spontaneous rhythmand maintain spontaneous perused rhythm

After defibrillation in the first minute the rhythm

spontaneously slowing and no create pulses so must

immediate initiate CPR cycle after defibrillation

Agonal gap it is a gap in the first minute after sudden

cardiac arrest (no responses, no pulses)

May used DC shock monphasic or biphasic or

AED(automated external defibrillators) if the DC shockmachine not known monphasic or biphasic used 200 j

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Monphasic start with 360j and biphasic constant used of

200j

VF and pulseless VTConsidered victims who unresponsive to BLS and no

responsive to the first shock

Drugs used in VF and VT vasopressin, epinephrine,

amidrone, lidocain, magnesium sulfate

VF and VT algorithm include

1. shockable : VT, VF

2. non shock able : PEA and a systole

algorithm start by BLS and call helpful team

Shockable rhythm (VT, VF)

1. shock : DC shock or defibrillators as protocol

2. immediate 5 cycle CPR and still CPR until

defibrillation is charge

3. give other one shock and perform 5 cycle CPR

4. give vasopressin and epinephrine as protocol

5. shock and 5 cycle CPR performed immediate andcheck rhythm

6. used anti arrhythmias drugs as amidrone, lidocain or

magnesium sulfate if torsad de pointes

7. then perform 5 cycle CPR

8. repeated if still VT or VF

9. move to other algorithm if change rhythm

Non shockable rhythm (PEA and a systole)

1. 5 cycle CPR

2. vasopressin and epinephrine as protocol

3. considered atropine

4. 5 cycle CPR and check rhythm

5. if still repeated same algorithm but if change used the

other algorithm depend on the new rhythm strip

produced

during CPR management H's, and T's

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the recommendation of shockable is 3 times

non shockable rhythm the QRS are narrowed and regular

if temperature less than 30 and patient with VF or VT

used hypothermia algorithm (rewarming procedure) theninitiate CPR because temperature 30 make unresponsive

body to drugs or pacing or defibrillation

drug given must followed by 20 cc fluid and rise hand for

10-20 second to facilitate delivery of drugs

hypovolemia is the most causes of PEA causes narrow

QRS and sinus tachycardia

causes of hypovolemia

1. hemorrhage, pulmonary embolism, cardiac

tamponade, ischemia

2. peripheral vascular dilation and myocardial

dysfunction after given over weighted drugs

if you face unclear situation as fine VF or asystole

differentiations considered fine VF is a prolong arrest so

must initiate 5 cycle CPR then can judged what is therhythm

asystole CPR continued 20 minute out side asystole no

need CRP if you witness a systole can perform CPR

immediate

Drugs of VF, VT

Vasopressin

Given IV\IO or in ETT

Vasopressin given as first or second dose not given as

third or more associated with epinephrine

Non adregenic peripheral vasoconstrictions

Epinephrine

Given in dose I mg and repeated it q 3- 5 min

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Alpha adregenic : effect to make vasoconstrictions of

cerebral and coronary artery to increase MAP and aortic

pressure

Amidrone:

Antiarrhythmia drugs used when patient un responsive to

shock

Affect of Na, K, Ca channel and considered alpha and

beta adregenic blocker

During CPR given 300 mg then 150 mg repeated every 3-5

min

Maximum amount of amidrone 2.2 gm\24 hr with

recurrent VF\ or VT based on cumulative toxicity

Recurrent VF\VT prescribed given amidrone as the

following

1. 150 mg in 10\min (bolus dose)

2. 360mg\nex 6 hr (1mg\min)and slow infusion

3. 540mg \18 hr (0.5 mg\min) as maintenance dose

During amidrone given observe hypotension, bradycardia,

GI toxicityLidocain

Antiarrhythmia drugs used if amidrone is not available

During CPR given 1-1.5 mg\kg first dose then 0.5-0.75

mg\kg (3 dose) repeated every 5-10 minute

The maximum dose of lidocain 3 mg\kg

Lidocain followed 1-4 mg\min after CPR

Magnesium sulfate

Used for patient with torsad de pointes and prolongation

of QT interval or patient with severe low magnesium level

Given in dose 1-2 gm diluted in 10 ml D5w need (5-20

minute)

Atropine

IV \IO or ETT given 1 mg every (3-5 min) and give just 3

doses

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Bradycardia

Bradydisarrhythmia : arrhythmia disorders with heart

rate less than 60 bpm, may found 40-50 bpm in athletes

persons

Bradycardia with escape rhythm : bradycardia dependant

of ventricle rhythm but considered normal myocardial

function but with abnormal conduction

Functional or relative bradycardia : heart rate 70 bpm in

case as cardiogenic shock or septic shock

Rhythm of bradycardia: sinus bradycardia, first \second

(1, 2)\ third heart block.

Complete heart block considered collapse and need TCP

Drug of bradycardia : atropine, dopamine(infusion),

epinephrine (infusion)

Symptoms of bradycardia

Chest discomfort and angina pain and SOB Decrease level of consciousness

H's Indicators Treatment

Hypovolemia Narrow complex,

rapid rate, flat

jugular vein

Volume infusion

Hypoxia Slow rate,

cyanosis, ABG

Oxygenation

Hydrogen ions

(acidosis)

DM, renal failure,

small amplitude

QRS complex

Sodium

bicarbonate

Hyperkalmeia T wave taller,

smaller p wave,

QRS wide, RF,DM, dialysis

glucose pulse

insulin, calcium

chloride, Sodiumbicarbonate,

dialysis

Hypokalemia U wave in ECG

QT prolong , QRS

wide

Infusion

potassium, added

magnesium

Hypothermia J or Osborn wave

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Dizziness, syncope, lighteners

Weakness, fatigue

Sing of bradycardia

Orthostatic BP

Diaphoresis

Pulmonary edema, CHF, PVC

Management of bradycardia

1. BLS primary survey and ACLS secondary survey

include:

A: maintain airway potency

B: give patient oxygen and monitor oxygen saturationC: IV access, ECG, Vitals sings

D: conduct with the problem and search with

contributing factors

2. If poor perfusion must prepare TCP(transcoetaneous

pacemaker ),

Sins and symptoms of poor perfusion: altered mental status,

hypotension, chest pain, and sings of shock.

3. if patient with adequate perfusion still monitored and

observation

4. if patient with poor perfusion must initiate the following

prepare TCP

give patient atropine as protocol of bradycardia

give patient epinephrine and dopamine as protocol of

bradycardia

5. treat causes under H's and T's and provide consultation

Transcoetaneous pacemaker (TCP)

TCP produce electrical depolarization and cardiac

contraction and impulses, it is also contain defibrillators

When apply TCP confirm it is mechanical and electrical

capture

Patient with hemodynamic instability and AV block type

2 and 3 with wide QRS complex must considered TCPimmediately.

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Ischemic patient should not increase heart rate in TCP to

not increase demand of oxygen and increase size of

ischemia and infarctions

Indication of TCP

1. Hemodynamic instability with bradycardia

(hypotension, altered mental status, angina, pulmonary

edema).

2. Sinus bradycardia, AV blocks, AMI. RBBB, LBBB

3. bradycardia with ventricular escape rhythm

4. tachycardia caused by drugs therapy or cardioversion to

organized heart rate

Contraindication of TCP

1.hypothermia, asystole

2.conscious patient until delay sedation( benzodiazepines,

analgesic)

3.carotid pulse not assess for patient with TCP because

TCP produce jerky movement and produce mimic

carotid pulse activity

When must used TCP

if ineffective atropine

patient become more symptomatic

IV access not quickly established

TCP technique

Connect the electrical way to machine and connect

electrode (one way toward patient and one toward themachine

Turn on

Put mood fixed(async) or demand(sync)

Select heart rate (60 bpm) or as order

Set cardiac output until capture occurs

Drugs for bradycardia

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Atropine:

Atropine is the first line given for symptomatic

bradycardia but also then can initiate TCP and other drugs

in atropine not respond

Atropine given in dose 0.5 mg until prepare TCP

If TCP ineffective can given atropine according (0.04*KG)

with maximum dose 3 mg

Atropine not give for patient with ischemia because it is

increase oxygen demand by increase heart rate and increase

ischemia and increase area of infarction

EpinephrineIf TCP is ineffective use Dose 2-10 mic\min

Dopamine

Dopamine alpha and beta adregenic action and can be

added to epinephrine or given alone

If TCP is ineffective use dose 2-10 mic\min (Chroutropic

or heart dose)

Pulmonary edema

1.assess BP and insert IV access and foleys catheter

2.give patient

morphine, oxygen, nitroglycerin, lasix

nitrocin given in dose 10-20 mic\min IV if systolic BP

more than 100mm.hg

dopamine or dobutamin to enhance pump action (2\10mic\min) IV

norepinephrine 0.5-3 mic\min IV

Hypothermia cases

Hypothermia patient who is temperature less then 36

1.remove wet garment

2.protect against heat lost and chills by use isolating blanket

3.put patient in horizontal position4.avoid rough movement and excess activity

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5.monitor cardiac rhythm, core temperature, responsive,

breath

If patient breathe and pulse present management as the

following:

1.mild hypothermia( T between 34-36 )

passive rewarming

active external rewarming: hot fluid, hot blanket)

2.moderate hypothermia (T between 30-34 )

passive rewarming

active external rewarming of the truncal area (trunk)

3.sever hypothermia (T

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Tachyarrhythmia : rhythm of the heart rate more than

100 bpm symptomatic or asymptomatic

Tachycardia may be considered stable or unstable

Tachycardia lead to decrease cardiac output and lead toCHF and pulmonary edema, and decrease blood flow to vital

organs

Rhythm of unstable tachycardia: atrial fibrillation, atrial

flutter, subraventricular tachycardia (SVT), monomorphic

VT, polymorphic VT and wide QRS complex tachycardia

with uncertain type.

Drugs used in case of unstable tachycardia: cardioversion,

sedationSymptoms of unstable tachycardia:

SOB, chest pain

Altered mental status

Weakness, fatigue

Fainting( pre syncope), syncope

Sins of unstable tachycardia

Hemodynamic instability (hypotension and sings

of shock)

Hypotension

Ischemia in ECG

PE and CHF

Poor peripheral perfusion manifested by: altered

mental status, cold extremities, decrease urine output

Management of unstable tachycardia:

1.maintain BLS and ACLS as the following

A: airway patent

B: give oxygen and suction and measure oxygen

saturation

C: vital sings, ECG, IV access

2.observe sings and symptoms of unstable tachycardia as the

following (altered mental status, hypotension, sings of shock,

syncope, fainting)

3.prepare cardioversion immediate( no choice)and

considered sedation

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4.some times patient with unstable tachycardia and wide

QRS complex as a complex situations so must considered as

case of VT

Stable tachycardia

Heart rate exceed 100 bpm and not exceed 180 bpm as

sinus tachycardia , also if heart rate 120-130 bpm when

patient rest

Sinus tachycardia considered physiological condition

increased by fever, blood loss, exercise

Drugs of stable tachycardia is adenosine and may used

Antiarrhythmia drugsManagement of stable

Management of stable tachycardia:

1.maintain BLS and ACLS as the following

A: airway patent

B: give oxygen and suction and measure oxygensaturation

C: vital sings, ECG, IV access

2.management as classification of stable tachycardia

A.stable with narrow QRS complex and regular HR

(QRS narrow

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If not conversion give patient 12 mg adenosine

(third dose) bolus dose with 20 cc normal saline and

rise the head and wait 2 minute)

If patient become unstable prepare immediatecardioversion

If patient conversion

It is probable to reentry SVT : treated with

adenosine or long AV bloke agent as diltazm or Beta

blocker

If patient not conversion

Possible to convert to atrial flutter , ectopic atrial

tachycardia, or junctional tachycardia can initiatedby long AV blocker as diltazm and B-blockers drugs

AV blocker not given to patient with CHF, PE

Then provide expert consultation

B.stable with narrow QRS complex and irregular HR(QRS narrow0.12 second)

As monomorphic VT or uncertain rhythm used

amidrone (150mg in 10 minute) and can repeat it

until maximum dose 2,2 g\day

Prepare elective cardioversion

If SVT occurs prepare adenosine

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If patient become unstable prepare immediate

cardioversion

D.stable with wide QRS complex and irregular HR

(QRS wide >0.12 second)As AF and WPW or polymorphic VT

Expert consultation

Avoid AV node blocker (adenosine, digoxine,

verpamil, diltazm

Considered amidrone

If torsades de pointes considered magnesium sulfate

(1-2 g in 5-60 min infusion

If patient become unstable prepare immediatecardioversion

Cardioversion and defibrillations

Not recommended in case junctional tachycardia, MAT,

ectopic because it is rising the depolarization and increase

rate

Mode of defibrillation is tow type

1. synchronized : used sensors

to deliver shock synchronized with QRS complex by

press sync bottom given in low energy

2. Asyncronized : shock deliver

any where In cardiac cycle but must given in high

energyAs case of polymorphic VT and VF or accelerate

tachycardia the sensors can not select QRS complex in

cardiac cycle so can not delivers cardioversion.

Indication of cardioversion:

1. Sinus tachycardia: physiological effect as responses to

extrinsic factors that need to increase CO, as person

with high sympathetic tones and high neural activity,

exercise

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2. atrial flutter : ( if person with heart rate 150 bpm and

under Antiarrhythmia drugs and complain of systemic

cardiac disease considered stable)

3. heart rate >150 bpm and unstable hemodynamic

4. patient seriously ill with cardiac disease and lower

heart rate

increase ventricular rate than 150 bpm not considered to

cardioversion

paddle can not used for synchronized just for monitoring

and fibrillation (not used in same time monitor and

cardioversion)

patient treat by cardioversion in the following cases1. patient with stable tachycardia with wide QRS complex

and regular rhythm

2. patient with unstable tachycardia with pulses

when patient become unstable initiate cardioversion as the

following(synchronized)

1. atrial fibrillation , SVT, monomorphic VT start at

100j-200j-300j-360j in monphasic

2. atrial flutter: start at 50j-100j-200j-300j-360j

in case of polymorphic VT and VF initiate defibrillations

Drugs of stable tachycardia

Adenosine

given in 3 doses 6g-12mg-12mg

Adenosine given and must followed by 20 ml directlynormal saline and rise the hand for 20 second

Adenosine not used to block AV and terminate

approximately 90% of reentry arrhythmia within 2 minutes

Adenosine not terminate atrial fibrillation and atrial

flutter but blocks AV conductions

Adenosine interaction with other drugs if given in large

dose as caffeine, theobromide, and theophillin

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Addsenosine start with 3 mg as minimal dose if patient

under treatment drugs as ( dipyrimadole or carbamazepine)

or patient with heart transplantation

Contraindication of adenosine :1.wide QRS complex

2.patient with airway disease( cause bronchial spasm)

Acute stroke cases

stroke : a general term refer to acute neurotically

impairment follow interruptions of blood supply to a

specific area in brain

type of stroke1. ischemic stroke : 85% of total case of stroke caused by

occlusion of an artery region in brains

2. hemorrhagic stroke : 15% of total cases where blood

vessels rupture into surrounding tissue hemorrhage

patient with hypertension or with atrial fibrillation

considered high risk and can not monitored sings of stroke

ECG is not take apriority over obtaining CT scan but

ECG can give resent MI or atrial fibrillation which may

lead to stroke

Do not delay CT because ECG just you can perform 12

ECG until CT is prepared

Drugs of stroke:

1. fibrinolytic therapy (tPA): tissue palsmogen activators

2. glucose50

3. labetol

4. nitropursside

5. nicardipine

6. aspirin

the main purpose of fibrinolytic therapy is reperfusion

acute ischemia (minimize brain injury and maximize patient

recovery)

diagnosis and treatment of stoke depend on 7 D's as thefollowing

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1. detection : onset sings and symptoms of stroke

2. dispatch of EMS

3. delivery: advanced pre hospitals notification

4. door : urgent triage in ED

5. data : computed tomography (CT) initiated

6. decision : treatment of fibrinolytic or not

7. during administration drugs and monitoring

period of assessment and management

1. 10 min :immediate general assessment in and order CT

2. 25 min :neurological assessment CT

3. 45 min :interpretation CT

4. 60min: administer fibrinolytic therapy after hospital

treatment and assessment

5. 3hr: treatment of fibrinolytic therapy after sings onset

appears

Algorithm of stroke:

1.identify the possible sings and symptoms:

sudden weakness and numbness in face, arm, leg in one

side

sudden confusiontrouble spelling or understanding

sudden trouble seeing in one or both eyes

sudden trouble walking

dizziness, loss balance and coordination

sever head ache without unknown causes

2.clinical assessment :

support ABC

give oxygen (maintain oxygen >92% to prevent

hypoxemia and increase ischemia brain injury

established timing

check glucose

alert hospital and bring witness from family or caregiver

clinical assessment depend on:

1. Cincinnati assessment

Dropped : ask patient to observe teeth or smile

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Arm weakness : ask patient to close eyes and

hold both arms out

Abnormal speech : ask patient to speak and

observe slurred or not2. Los Angeles assessment : ask about :

Age>45

History of seizure or epilepsy

Symptoms duration

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if no contraindication given , in have contraindication

give patient aspirin

do not give patient anticoagulant or antiplatelet before

24 hr until if fibrinolytic contraindicationif hemorrhagic stroke

consultation neurosurgery or transfer to other

hospitals

admit to the stroke unit and observe glucose level,

blood pressure , neurological status

Hypertension management:

1.systole >220 and diastole >121-140

able to reduction BP 10-15% of total BP

labetol 10-20 mg IV for 1-2 min and can be repeated to

maximum dose 300 mg

Nicardipine 5 mg\hr infusion (start at 2,5mg\hr and

repeated every 5 min until maximum dose 15mg\hr

2.diastole >140

Able to reduction BP 10-15% of total BP

Nitropursside 0.5 mic\min IV infusion with continuousmonitor BP

Care in intensive care unit:

1.support airway , oxygen, ventilation, nutrition

2.avoid GW fluid infusion

3.give patient 70-100 ml\hr normal saline

4.monitor hyperglycemia >200

5.treat fever ( Acetaminophen)

Fibrinolytic therapy:

tPA is given within 3 hr of onset symptoms

major complication of tPA is intracranial hemorrhage,

andioedema, transient hypotension

may be considered IV therapy or intra arterial therapy if

IV therapy have contraindication

tPA checklist

Inclusion criteria ( mean yes given)

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age > 18

clinically diagnosed stroke

time of onset symptoms 185\110

Aneurysm, neoplasm, male formation in arteriovenous

systemSeizure

Active internal bleeding or acute trauma

Acute bleeding disorder as ( platelet 1,7 or PT > 15

second

Intracranial or intraspinal surgery or serious head

trauma within 3 months

Relative exclusion criteria

Surgery within 14 days

GI or urinary bleeding

AMI within 3 months

Glucose level 400