CRASH CART FAMILIARIZATON& ARRYTHMIAS

E.R. STAFF

Define the term crash cart Understand the purpose of crash cart Identify the content of crash cart, their

use and the nursing consideration for all the:

medicationsSupplies

Objectives

A crash cart or code cart is a special mobile unit with drawers used in health care facilities and emergency rooms that contain the necessary medications and equipment to respond to a cardiopulmonary arrest.

Definition of Crash Cart

The purpose of the crash cart is to have a portable life saving unit that contains all the medications, supplies and equipment necessary to initiate a treatment in emergency and life threatening situations on all health care facilities.

Purpose of Crash Cart

1. Crash cart must be checked by head nurse/staff nurse every shift and document in checklist

2. Standarization must be maintained.3. Defibrillator will be checked by biomed

department regularly or as necessary.4. Crash cart items must be checked monthly

for expiry dates.5. Each unit will have crash cart placed in and

easily place accessible location.

Policy

Top shelf Defibrillator and manual spO2 probe ECG strips Ultrasound jelly for DC Shock Checklist Right sideAdjustable iv pole Ambu bag adult with mask Ambu bag pedia with mask Oxygen cylinder

Arrangement of Crash Cart

Top SlidePenlightStyletScissorsMagills forcepExtra batteryLidocaine GelCurve/straight forcepLaryngoscopeDisposable razorsAirway different sizes

Chest leads Chest electrodes Conductive gel ECG recording paper Defibrillator paddlesTo know the rhythm and or delivering

shock

defibrillator

First Drawer

EMERGENCY DRUGS Adenosine Adrenaline Amiodarone Aminophylline Atropine Calcium Chloride Dexamethasone Diazoxide Digoxin Dopamine Sodium bicarbonate Procainamide Dextrose 50%

Dobutamine Isoproterenol Magnesium Sulfate Methylprednisolone Noradrenaline Hydrocortisone Furosemide Calcium chloride Potassium chloride Propranolol Verapamil Vasopressin Lidocaine 1% and 2% Hydralazine

AIRWAY/BREATHINGOxygen mask (Adult/Pedia)Nasal cannula/cathAdul/pedia neb. KitETT all sizesLAMAStyletNasopharyngeal tubes

Second Drawer

CIRCULATION IV Set IV cannula all sizes 3way stopcock Foley catether NGT all sizes Blood transfusion set Syringes all sizes BP APP TORNIQUET

Third Drawer

IV Fluids RL NS D5W D5NS ½ D5NS ¼ D5NS D10 HUMAN PLASMA ALBUMIN MANNITOL EXTRA AMBUBAGS

FRONT SIDE CARDIAC BOARD

Lower Portion

Adenosine Antiarrhythmic Conversion to sinus rhythym of paroxysmal

supraventricular tachycardia Dose: 6mg by rapid bolus: for repeat dose, use

12mg by IV bolus within 1-2 mins.

Epinephrine Adrenergic agent choice for cardiac arrest,

vasopressor used in Pulseless VT/VF, Asystole and PEA

Dose : 1mg IV every 3-5mins or more frequently. May be given endotracheal route.

Stocked 1mg/ 10ml 1:10,000. If used for hypersensitivity reaction 0.1- 0.25mg

SC

EMERGENCY DRUGS

AMIODARONE (antidysrhythmics, 3rd)-malignant Ventricular Arrythmia, V-Fib/Pulseless V-

Tach-markedly prolongs action potential and

repolarization-300 mg IV x1 after dose of epinephrine if no initial

response to defibrillation. May repeat 150 mg IV q5-10min. Rapid IV push if pulseless/no BP.

Not to exceed 2.2 g/day, may be diluted in N.S. or D5W

AMINOPHYLLINE (Xanthine Derivatives)-Acute Bronchospasm-Methylxanthines directly relaxes the smooth

muscle of the Respi Tract.-6 to 7 mg/kg IV/PO; infuse iv over 20 mins

Atropine Sulfate Parasympatholytic Anticholinegic Antidote for organophosphate poisoning Agent used for symptomatic bradycardia, PEA Dose : 0.5-1mg IV push, repeat at 3-5 mins Intervals to max. total dose of 0.4mg/kg May b given via endotracheal route. Stocked 1mg/

10ml

Digoxin

-(antidysrhythmics, 5th, inotropic agents)-heart failure, A-FIB,-0.4-0.6 mg once then may cautiously give add’tl doses

of 0.1-0.3 mg q6-8hrs until adequate.-slow IV push over 5 mins

DOBUTAMINE-inotropic agents-low cardiac output and CHF-0.5-1 mcg/kg/min IV initially, then 2-20

mcg/kg/min; not to exceed 40mcg/kg/min-infuse to large vein via infusion pump

DOPAMINE-inotropic agents-hypotension, cardiac output and poor perfusion of

vital organs. Mean arterial pressure in Septic shock patients

-in large vein, via infusion pump.

D50W (glucose-elevating agents)-hypoglycemia-10-25g (20-50ml 50% solution)-high concentrations should be administered via Central Veins

and only after appropriate dilution

SODIUM BICARBONATE-alkalinizing agent-cardiac arrest, hyperkalemia-1 mEq/kg/dose IV x 1

POTASSIUM CHLORIDE (Electrolytes)-conduction of nerve impulses in the heart, contraction of

cardiac, smooth muscle-hypokalemia-40 to 100 mEq KCL diluted in an appropriate amount and type

of solution to be intravenously infused once at a rate not to exceed 10 to 40 mEq/hour.

CALCIUM GLUCONATE-antidote, calcium salts-hypocalcemia (hypocalcemic tetany,

hypoparathyroidism) cardiac arrest (+ hyperkalemia, hypocalcemia, hypermagnesemia)

-1.5-3g IV over 2-5 minutes, diluted in N.S or D5W-rapid IV admin.: arrythmias, hypotension, M.I. or

vasodilation

CALCIUM CHLORIDE-antidote, calcium salts-hypocalcemia, arrythmias, hypermagnesemia-500-1000mg IV over 5-10 mins/-C/I in Vfib during CPR,PVT

DEXAMETHASONE (corticosteroid)-hormones and synthetic substitutes-inflammation, cerebral edema and shock-1-6 mg/kg IV or 40 mg IV q2-6hrs PRN, diluted in D5W, N.S.

DIAZOXIDE (Glucose Elevating Agents)-hyperinsulinemic hypoglycemia-now in oral form. -the injectable form used for HTN emergency is no longer

available

FUROSEMIDE (loop diuretic)-edema asso. With CHF, liver cirr. & Renal dse. HTN-A.Pulmonary Edema, HTN crisis, ICP- 0.5-1mg/kg (40mg) IV over 1-2 mins. Or up to 80 mg but should

not exceed 200mg -hyperkalemia, hypermagnesemia (hpk: 40-80 mg IV; hpm: 20-

40mg iv/q3-4hrs PRN)

HYDRALAZINE (vasodilators)-HTN crisis, CHF-^ 10-50 mg IM, or 10-20 mg IV, repeat PRN-may induce SLE-type syndrome-D5W

HYDROCORTISONE (corticosteroids)-status asmaticus, anti-inflammatory &

immunosuppressive-Initial dose: 100mg -500mg PRN, may repeat q2, 4,

6hrs PRN

ISOPROTERENOL-beta 1/beta2 adrenergic agonist-V.A’s due to (AV) heart block, Adams-Stokes attacks,

cardiac arrests and shock-IV Bolus: 0.2-0.06mg initially THEN doses of 0.01-

0.2mg.-IV Infusion: .5mcg/min, THEN doses of 2-20mcg/min.

by infusion pump in D5W* Direct IV, IM, SC or Intracardiac inj.(EXTREME cases)

MAGNESIUM SULFATE (antidysrhythmics, V, Electrolytes)

-hypomagnesemia, toxemia of Pregnancy and Torsades de Pointes V-TACH

-with Pulse: 1-2g slow iv (10ml/D5W) over 5-60 mins, then 0.5-1g/hr IV

-Cardiac arrest: same as above but over 5-20 mins.

METHYLPREDNISOLONE (corticosteroids)-allergic conditions, acute exacerbations of multiple sclerosis, -dose: 10-250 mg IM/IV up to q4hr PRN

NITROGLYCERINE (nitrates) ANGINA, Renal Failure-5mcg/min. if unresponsive to SL NTG-increase by 5 mcg/min q3-5mins up to 20mcg/min.-3ml/hr (50mg in 250ml D5W/NS)

NORADRENALINE (alpha/beta adrenergic agonist)-acute hypotension, cardiac arrest, sepsis/septic shock-initial: 8-12mcg/min IV Infusion. Titrate.*extravasation: infiltrate with 10-15ml NS+5-10mg of

phentolamine mesylate.*monitor BP

PROCAINAMIDE (antidysrythmics, 1a) arrythmia, IM: 0.5-1g IM q4-8hr IV: loading dose 15-18 mg/kg; slowly over 25-30

mins; may repeat q5mins PRN; not to exceed 1g. Sol’n: 2g/250ml D5W/NS , in infusion pump

PROPRANOLOL(antidysrhythmics, II) beta-blockers(nonselective), antianginal-HTN, ANGINA, Hypertropic SubAortic Stenosis,

SupraVentricular arrythmia & Portal HTN.-SVA: 1-3mg at 1 mg/min 1st, repeat q2-5 min until

5mg. Once achieved, no add’l dose for at least 4 hours.

LIDOCAINE (anesthetics pre-med agents) Cardiac arrythmias: 1.1-5mg/kg, slow IV over 2-

3mins (3mg/kg total) IV, IO/ET..Can be given IM! If, no IV and no ECG, for

V.Ar

VASOPRESSIN (antidiuretics)-Abdominal distention, Diabetes Insipidus,

Gastrointestinal Hemorrhage and vasodilatory shock.

-AD: initial: 5 units/IM, repeat q3-4hrs PRN up to 10 units.

-DI: 5-10 units IM/SC/intranasal q6-12 hrs.-dilute to NS/D5W and via controlled infusion device.

Verapamil Antianginal Antiarrhythmic Antihypertensive Calcium channel blocker Therapeutic actions: -inhibits the movement of calcium ions across the membranes of cardiac and arterial muscle cells Indications: treatment of SVT, essential hypertension Dose: Adult- IV initial dose- 5-10mg over 2mins; may repeat dose of 10mg 30 mins after first dose Pedia- 1year and younger: initial dose 0.1-0.2mg/kg over 2 mins.1-15 years: initial dose 0.1-0.3mg/kg over 2mins. Do not exceed 5mg. Repeat above dose 30mins after initial dose if response is not adequate. Repeat dose should not exceed 10mg.

Monitor patient carefully (BP, cardiac rythym, and output)

Protect IV solution from light Monitor patients with renal or hepatic

impairment carefully for possible drug accumulation and adverse reactions

Nursing Considerations

Dose: IV Adult: 150mg loading dose over 10mins, followed by 360mg over 6hr at rate of 1mg/min

For maintenance infusion 540mg at 0.5mg/min over 18hr

Remember Amiodarone should be diluted with D5W

An arrhythmia is an irregular heartbeat - the heart may beat too fast (tachycardia), too slowly (bradycardia), too early (premature contraction) or too irregularly (fibrillation). Arrhythmias are heart-rhythm problems - they occur when the electrical impulses to the heart that coordinate heartbeats are not working properly, making the heart beat too fast/slow or inconsistently. Many heart arrhythmias are harmless. We all occasionally experience irregular heartbeats, which may feel like a racing heart or fluttering. Some arrhythmias, however, especially if they veer too far from a normal heartbeat or result from a weak or damaged heart, may cause troublesome and even potentially fatal symptomsRapid arrhythmias are called tachycardias, while slow ones are called bradycardias. Irregular arrhythmias - when the heartbeat is irregular - are called fibrillations, as in atrial or ventricular fibrillation. When a single heartbeat occurs earlier than it should it is called premature contraction.

ARRHYTHMIAS

The English word "arrhythmia" comes from the Greek word rhymos, meaning "rhythm", the Greek suffix a (letter "a" added to the beginning of a word) means "loss" - put together they mean "loss of rhythm". 4 MAIN TYPES1. Premature (extra) beats2. Supraventricular arrhythmias3. Ventricular arrhythmias4. Bradyarrhythmias

PREMATURE (EXTRA) BEATS- Most common type. They are harmless most of the time and often don’t cause any symptoms. Premature beats that occur in the atria (the heart’s upper chambers) are called premature atrial contractions, or PACs. Premature beats that occur in the ventricles (the heart’s lower chambers) are called premature ventricular contractions or PVCs.

SUPRAVENTRICULAR ARRHYTHMIAS

-are tachycardias (fast heart rates) that starts in the atria or atrioventricular (AV) node. The AV node is a group of cells located between the atria and the ventricles.

Types of SV ArrhythmiasAtrial Fibrillation (AF)Atrial FlutterPSVTWolff-Parkinson-White

VENTRICULAR ARRHYTHMIA-Starts at the heart’s lower chambers, the ventricles. They can be very dangerous and usually require medical care right away.Includes: Ventricular Tachycardia is a fast, regular beating of the ventricles that may last for only a few seconds or much longer.Ventricular Fibrillation is disorganized electrical signals make the ventricles quiver instead of pump normally. Without the ventricles pumping blood to the body, sudden cardiac arrest and death can occur within a few minutes.

BRADYARRHYTHMIAS-Occur if the heart rate is slower than normal. If the heart rate is too slow, not enough blood reaches the brain. This can cause you to pass out.-in adults, a heart rate is slower than 60 beats per minute is considered bradyarrhythmia. Some people normally have slower heart rates, especially people who are very physically fit. For them, a heart beat slower than 60 beats per minute isn’t dangerous and doesn’t cause symptoms. But in other people, serious diseases or other conditions may cause bradyarrhythmias.-can cause Heart attacks Conditions that harm or change the heart’s electrical

activity, such as an underactive thyroid gland or aging An imbalance chemicals or other substances in the blood,

such as potassium Medicines such as beta blockers, calcium channel blockers,

some antiarrhythmia medicines, and digoxin

Arrhythmia in children Children’s heart rates normally decreases as they get older. A

newborn’s heart beats between 95-160 times a minute. A 1 year old heart beats between 90- 150 times a minute, and a 6 to 8 year old heart beats between 60 to 110 times a minute.

A baby or child's heart can beat fast or slow for many reasons. Like adults, when children are active, their hearts will beat faster. When they're sleeping, their hearts will beat slower. Their heart rates can speed up and slow down as they breathe in and out. All of these changes are normal.

Some children are born with heart defects that cause arrhythmias. In other children, arrhythmias can develop later in childhood. Doctors use the same tests to diagnose arrhythmias in children and adults.

Treatments for children who have arrhythmias include medicines, defibrillation (electric shock), surgically implanted devices that control the heartbeat, and other procedures that fix abnormal electrical signals in the heart.

ARRHYTHMIAS

PULSELESS RHYTHYM

NON SHOCKABLEPEA (Pulseless Electrical Activity)Asystole (Silent Heart)

SHOCKABLEVF (Ventricular Fibrillation)VT(Ventricular Tach Pulseless)TORSADES de Pointes

Perfusing Rhythms(non-arrest rhythms)

BRADYCARDIASinus BradycardiaJunctional rhythymIdioventricular Rhythym

Artioventricular Block:1st degree2nd degree: Mobitz Type I Mobitz Type II3rd degree (Complete Heart Block)

TACHYCARDIAS: NARROW QRSRegular Rhythym:Sinus tacycardiaAtrial flutterSupraventricular TachycardiaJunctional TachycardiaIrreguar Rhythyms:Atrial flutterAtrial FibrillationMultifocal Atrial Tachycardia

TACHYCARDIAS : WIDE QRSRegular Rhythym:Ventricular tachycardia: monomorphicIrregular Rhythym:Ventricular Tachycardia: polymorphicTorsades de Pointes

Thank you!!!