POST CARDIAC ARREST

• Cardiac Monitoring


  Provides continuous observation of the patient's heart rate and rhythm and is a routine nursing procedure in critical care patients
• Cardiac Monitoring


  • Common in emergency units, post-anesthesia recovery units and operating rooms
• Cardiac Monitor


  A device that shows the electrical and pressure waveforms of the cardiovascular system for measurement and treatment. Parameters specific to respiratory function can also be measured.
• Electrocardiograph (ECG)


  A graphic record or representation of the electrical activity of the heart muscles
• Electrode Placement


  1. Electrodes detect the tiny electrical changes on the skin that arise from the heart muscle depolarizing during each heartbeat

  2. Electrodes are optimally placed directly on dry skin

  3. To prevent unclear ECG tracing, the following preparations are suggested: a) Shaving the skin if necessary, b) Removing dead skin cells by rubbing the area with a rough paper or cloth, c) Removing oil, grease and dirt using alcohol, and d) Using electrodes from airtight packages

  4. In emergency situation, healthcare providers use 3 or 5 leads of electrodes because they have no plenty time to attach those electrodes
• Limb Leads


  • Bipolar I, II, III
  • Augmented aVR, aVL, aVF
• Chest Leads


  • Precordial V1, V2, V3, V4, V5, V6
• 1. Lead ECG System


  Attaching 3 electrodes on the patient's chest. "White on the Right, Smoke over Fire"
• 1. Lead ECG System


  Attaching 5 electrodes on the patient's chest. "Snow over Grass, Melt Chocolate". Add the green and brown electrodes for 5-lead electrodes.
• Precordial Lead Placement


  • V1 Fourth intercostal space at the right sternal edge
  • V2 Fourth intercostal space at the left sternal edge
  • V3 Midway between V2 and V4
  • V4 Fifth intercostal space in the mid-clavicular line
  • V5 Left anterior axillary line at same horizontal level as V4
  • V6 Left mid-axillary line at same horizontal level as V4 & V5
• Normal Sinus Rhythm (NSR)


  Rate 60-100 bpm, Rhythm regular, P-wave precede QRS, consistent shape, PR Interval 0.12 to 0.20 second, QRS Complex 0.04 to 0.10 second, Conduction normal flow

  
• Sinus Bradycardia


  • Can be normal findings in athletes during sleep; may be a response to vagal simulation and certain medications (digitalis, beta-blockers, calcium channel blockers); seen in patients with increased ICP, uremia, myxedema and obstructive jaundice
• Sinus Tachycardia


  • A normal response to exercise and emotion; and can be caused by some medications (e.g. ephinephrine, dopamine, caffein)
• Sinus Arrhythmia


  • Occurs when sinus node discharges irregularly, and is a normal phenomenon during respiration; may be caused by digitalis toxicity
• Sinus Arrest


  • Occurs when impulses from the sinus node are not formed as expected (p-wave absent at some point); also known as sinus pause; causes include vagal simulation and drugs (digitalis, beta-blockers, calcium channel blockers)
• Atrial Flutter


  • Caused by fixed re-entry circuit in the right atrium on patients with health concerns (e.g. rheumatic heart disease, atherosclerotic heart disease, heart failure, myocardial infraction)
• Atrial Fibrillation


  • An extremely rapid and disorganised pattern of depolarisation; most commonly seen in adults post cardiac surgery and with conditions such as rheumatic heart disease, pulmonary disease , MI, and congenital heart disease
• Ventricular Asystole


  • Absence of any ventricular rhythm

  
• Ventricular Fibrillation


  • Rapid, ineffective quivering of the ventricles; no cardiac output or palpable pulse (fatal without immediate treatment)
• Supraventricular Tachycardia


  • Rapid rhythm of the heart that begins in the upper chambers

  
• Ventricular Tachycardia


  • Rapid ventricular rhythm; commonly caused by coronary artery diseases
• First Degree AV Block

  • Prolonged AV conduction to the ventricles; due to coronary artery disease, rheumatic heart disease and administration of some drugs (e.g. digitalis, beta- blockers or calcium channel blockers)
• Second Degree AV Block (Type 1)

  • Occurs when one atrial impulse at a time fails to be conducted to the ventricles (occurs at AV node)
• Second Degree AV Block (Type 2)

  • Occurs when one atrial impulse at a time fails to be conducted to the ventricles (occurs below AV node)
• Third Degree AV Block

  • Complete failure of conduction of all atrial impulses to the ventricles
• 15 ECG Readings


  • 4 - Sinus – Normal BUT… (Complete PQRST)
  • 2 – Atria – Piercing (Pins)
  • 4 – Ventricles – The Grass (No Negative Deflection)
  • 4 – AV Blocks – With Defects (Deficient PQRST)
• Managements in ACLS - Slow Rhythm (Bradycardia)

  1. Atropine Sulfate - Pharmacological intervention, Dose: 0.5 mg, Max: 3 mg, Total: 6 doses, Interval: 3-5 mins

  2. Transcutaneous Pacing - Procedure, Delivery of small electrical current to temporarily restore electrical activity of the heart, Demand TCP – delivers electrical stimulus only when needed, Fixed Rate TCP – delivers electrical stimuli at a selected rate regardless of patient's intrinsic cardiac activity

  3. Dopamine Infusion - Pharmacological intervention, Renal Dose = 2 mcg/kg/min, Cardiac Dose = 5 mcg/kg/min, Vasopressor Dose = 10 mcg/kg/min

  4. Epinephrine Infusion - Pharmacological intervention, Titrate to response, Initial: 2 mcg/ min, Max: 10 mcg/min, Can increase up to 4 mcg/min if the client does not response to the medication. Stop if there's a response.

  
• Managements in ACLS - Fast Rhythm (Tachycardia)

  1. Stable: Physiologic (Natural) - Vagal maneuver (massaging the carotid) Allow the client to cough, Pharmacologic - Adenosine: Min = 6 mg; Max = 12 mg

  2. Unstable: Sedate - Diazepam = 5 mg, Medazolam = 5 mg, Synchronized Cardioversion - SVT = 50 J, AF = 120 J

  
• Roles in ACLS


  • Team Leader
  • Compressor
  • Monitor Defibrillator
  • Airway
  • IV/ IO/ Medications
  • Timer/ Recorder

  
• American Heart Association Guidelines
• Roles in a cardiac arrest response team

  • Compressor
  • Monitor Defibrillator
  • Airway
  • IV/IO/Medications
  • Timer/Recorder
• Monitor Defibrillator


  • Brings and operates the AED monitor/defibrillator
  • Acts as the CPR Coach if designated
  • Places the monitor in a position where it can be seen by the team leader (and most of the team)
  • Partner of compressor
  • Checks the cardiac monitor and provides shock if necessary

  
• Airway


  • Opens the airway
  • Provides bag-mask ventilation
  • Inserts airway adjuncts as appropriate
• IV/IO/Medications


  • Initiates IV/IO access
  • Prepares and administers the medications
• Timer/Recorder


  • Records the time of interventions and medications (and announces when these are next due)
  • Records the frequency and duration of interruptions in compressions
  • Communicates these to the team leader (and the rest of the team)
  • Documents all the procedures
• ACLS providers functioning within a high-performance team can choose the optimal approach for minimizing interruptions in chest compressions
• There are different protocols to maximize chest compression fraction and high-quality CPR
• High-performance teams


  • Essential to successful resuscitation attempts
  • Translate to improved survival for patients in cardiac arrest
  • Effectively incorporate timing, quality, coordination, and administration of the appropriate procedures
  • Clearly identify their overall purpose and goals
  • Aware of the skills each member possesses and understand their motivation, strengths and weaknesses
  • Incorporate effective conflict resolution and communication skills
  • Continually measure their performance, evaluate the data, look for ways to improve performance, and then implement those learnings
• Chest Compression Fraction (CCF)


  The amount of time spent doing high quality chest compressions during a cardiac arrest event
• A 10% increase in CCF is roughly equal to an 11% increase in survival