Wednesday, February 29, 2012

Pediatric Advance Life Support: Asystole Part 4


Medication Dose Calculation
·         Use the child’s weight if it is known
·         If the child’s weight is unknown, it is reasonable to use a body length tape
·         No data regarding the safety or efficacy of adjusting the doses for obese patients

Broweslow Tape


IV Access
·         Peripheral IV
·         Central line
·         Intraosseous
·         Intratracheal

Intraosseous (IO) Access
·         All intravenous medications can be administered intraosseously
·         Onset of action and drug levels are comparable to venous administration
·         IO access can be used to obtain blood samples for analysis
·         Use manual pressure or an infusion pump to administer viscous drugs or rapid fluid boluses
·         Follow each medication with a saline flush

Peripheral IVs
·         Placement may be difficult in a critically ill child
·         Central venous placement requires procedure can be time consuming

Endotracheal Drug Administration
·         Lipid-soluble drugs, such as lidocaine, epinephrine, atropine, and naloxone (mnemonic “LEAN”)
·         Effects may not be uniform with tracheal as compared with intravenous administration
·         Expert consensus recommends doubling or tripling the dose of lidocaine, atropine or naloxone
·         Epinephrine 0.1 mg/kg or 0.1 mL/kg of 1:1000 concentration is recommended

ET tube Medication Administration
·         Dilute the dose in 2 to 5 mL saline
·         Remove ambu bag from ET tube
·         Inject it into the ET tube
·         Replace ambu bag on ET tube
·         Administer 2 to 3 breaths with the ambu bag

Central IV Drug Delivery
                    Peak drug concentrations are higher and drug circulation times shorter
                    Central line placement can interrupt CPR.
                    A central line extending into the superior vena cava can be used to monitor ScvO2 and estimate CPP during CPR, both of which are predictive of ROSC


Tuesday, February 28, 2012

Pediatric Advance Life Support: Aystole Part 3


Confirm ET tube placement
n  Direct cord visualization
n  End-tidal CO2 monitor
n  Purple- problem
n  Yellow- yes
n  Tan- think about it
n  Bilateral breath sounds
n  CXR
n  Continuous waveform capnography

Note:  Continuous quantitative waveform capnography is now recommended for intubated patients throughout the periarrest period as a means of both confirming and monitoring correct placement of an endotracheal tube. 

Esophageal Detector Device (EDD)
·         May be considered in children weighing ≥ 20 kg with a perfusing rhythm
·         Insufficient data to recommend for or against its use in children during cardiac arrest

Verification of Endotracheal Tube Placement
·         Verify proper tube placement immediately after intubation
·         After securing the endotracheal tube
·         During transport
·         Each time the patient is moved (eg, from stretcher to bed)

DOPE Mnemonic
·         If an intubated patient’s condition deteriorates
·         Displacement of the tube
·         Obstruction of the tube
·         Pneumothorax
·         Equipment failure

Exhaled or End-Tidal CO2 Monitoring
·         Recommended as confirmation of tracheal tube position
·         Confirms tube position in the airway but does not rule out right main stem bronchus intubation
·         During cardiac arrest the absence of CO2 may reflect very low pulmonary blood
·         Persistently low PETCO2 values (<10 mm Hg) during CPR in intubated patients suggest that ROSC is unlikely
·         If PETCO2 is <10 mm Hg, it is reasonable to consider trying to improve CPR quality by optimizing chest compression parameters

Note:  Although a PETCO2 value of <10 mm Hg in intubated patients indicates that cardiac output is inadequate to achieve ROSC, a specific target PETCO2 value that optimizes the chance of ROSC has not been established. Monitoring PETCO2 trends during CPR has the potential to guide individual optimization of compression depth and rate and to detect fatigue in the provider performing compressions


End-tidal CO2 detector may be altered by the following:
·         Detector is contaminated with gastric contents or acidic
·         An intravenous (IV) bolus of epinephrine may transiently reduce pulmonary blood flow and exhaled CO2 below the limits of detection
·         Severe airway obstruction and pulmonary edema may impair CO2
·         Large glottic air leak may reduce exhaled tidal volume 

Monday, February 27, 2012

Pediatric Advance Life Support: Aystole Part 2


Mnemonic for Treating Asystole:  CAVE
C- CPR
A-assess rhythm in another lead
V-vasoconstrictors
E- evaluate reversible causes

CPR:  Primary Survey
·         Assess patient
·         Support ABCs
·         CPR
·         Attach defibrillator/monitor
·         Assess rhythm

The effectiveness of PALS is dependent on high-quality CPR
·         Adequate compression rate (at least 100 compressions/min)
·         Adequate compression depth (at least one third of the AP diameter of the chest or approximately
·         1 1⁄2 inches [4 cm] in infants and approximately 2inches [5 cm] in children)
·         Allowing complete recoil of the chest after each compression
·         Minimizing interruptions in compression
·         Avoiding excessive ventilation

Assess Rhythm in Another Lead
·         Make sure correct lead is displayed on the monitor
·         Make sure cables are connected to the monitor
·         Check gain on monitor
·         Check for loose leads
·         Confirm that the rhythm is not fine VF


Asystole Confirmed in Two Leads














Fine ventricular fibrillation may look like asystole




Secondary Survey
·         Intubate
·         Oxygenate
·         IV access
·         Treat reversible causes

Note: Once the patient is intubated, continue CPR with asynchronous ventilations and chest compressions.
Formula for Estimating Endotracheal tube size: 
Uncuffed ET tube:  mm ID = (age in years/4) + 4
Cuffed ET tube:  mm ID = (age in years/4) + 3

Sunday, February 26, 2012

Pediatric Advance Life Support: Asystole Part 1

Non-profusing Rhythms
·         Pulseless electrical activity
·         Asystole
·         Agonal Rhythms
·         Ventricular tachycardia
·         Ventricular fibrillation

Cardiac Arrest in Infants and Children
·         Does not usually result from a primary cardiac cause
·         Terminal result of progressive respiratory failure or shock
·         Asphyxia begins
·         Period of systemic hypoxemia, hypercapnia, and acidosis
·         Progresses to bradycardia and hypotension
·         Culminates with cardiac arrest


Keys to Treating Pediatric Cardiac Arrest
·         Rapid recognition of the arrest
·         Immediate, high quality CPR
·         Correction of contributing factors and reversible causes



Asystole
·         Most common out of hospital pediatric arrest rhythm
·         Most often caused by combination of hypoxia and ischemia
·         Look for reversible causes
·         Outcome is generally very poor


Asystolic Rhythms
Aystole

Agonal rhythm

Ventricular fibrillation deteriorating to aystole

Saturday, February 25, 2012

EKG Rhythm Strips 37

Identify the following rhythms
1.
2.
3.
4.
5.






Answers
1.
NSR with multiple ectopic beats








The rhythm is irregular with multiple ectopic beats.   The ventricular rate is 96/min. (Count number of R waves in this 10 strip and multiple by 6).  The P waves are upright and have a corresponding QRS complex.    The are multiple ectopic beats present, 2nd 6th, 10th, 12th, 13th and 15th complexes.   There appears to be a P wave associated with the 1st and 2nd ectopic beats these are actually be fusion beats.   The 12th and 13th complexes are PVCs that form a multifocal couplet.  The 15th complex is a PVC that is followed by a compensatory pause and an atrial escape beat.  PR:  .20 sec,  QRS;  .10 sec,  QT:  .40 sec.


2.
NSR with unifocal PVCs








The rhythm is irregular with multiple PVCs.   The P waves are positive and are associated with a QRS complex.   There are unifocal PVCs present.   A compensatory pause follows each PVC.  PR:  .16 sec,  QRS:  .08 sec,  QT:  .38 sec.



3.
Atrial tachycardia









The rhythm is regular with a rate of 166/min.   The P waves are upright and are paired with a QRS complex.   The P waves are fused with the T wave of the previous complex.  No ectopic beats are noted.  PR:  .10,  QRS:  .06 sec,  QT:  .28 sec.


4.
NSR with ventricular trigemeny








The rhythm is irregular.   The heart rate is 90/min.  The P waves are upright and precede the QRS complexes.  There are multifocal PVC present in a trigeminal pattern. A compensatory pause follows each PVC. The ST segment is slopping downward and there is inversion of the T wave.   PR:  .20 sec,  QRS:  .08 sec,  QT:  .44 sec.


5.
Agonal rhythm changing to aystole











The rhythm is irregular.   The rate is 20/min.   There are no P waves present.   The QRS complex is wide and bizarre looking.   The rhythm changes to asystole after the 2nd complex.




Reviewed on 3/2/16

Friday, February 24, 2012

EKG Rhythm Strips 36

Identify the following rhythms
1.
2.
3.
4.

5.










Answers


1.
NSR with unifocal PVCs








The rhythm is irregular with a heart rate of 78/min.    The P waves are upright, uniform and associated with a QRS complex.   Two unifocal PVCs are seen.   PR:  .12 sec,  QRS:  .08 sec, QT:  .44 sec.


2.
Sinus bradycardia with a U wave










The rhythm is regular with a rate of 44/min.  The P waves are uniform and are paired with a QRS complex.  The P waves are wide and slightly notched suggesting biatrial enlargement.  No ectopic beats are noted.  A U wave follows each T wave.PR:  .16 sec,  QRS:  .10 sec,  QT:  .56 sec.  


3.
Atrial fibrillation with rapid ventricular response.  








The rhythm is irregular with a ventricular rate of 156/min.  The P waves are absent but there appears to be some fibrillatory waves in between some of the QRS complexes.   No ectopic beats are seen.   PR:  ---,  QRS:  .14 sec,  QT:  . 32 sec.


4.
Multifocal atrial tachycardia








The rhythm is irregular with a rate of 120/min.  The P waves are upright and precede a QRS complex. The morphology of the P waves and the PR interval varies on some beats, for instance the 2nd, 4th, and 6th complexes.  There must be at least 3 different P waves for the rhythm to meet the criteria for MAT.   There are multiple PACs present.  PR:  .12 sec,  QRS:  .08 sec, QT:  ---


5.
Idioventricular rhythm changing to agonal rhythm












The rhythm is irregular.   The morphology and rate of the QRS changes from an organized looking complex to one that is less organized.   No P waves are seen.



Reviewed on 3/2/16

Thursday, February 23, 2012

EKG Rhythm Strips 35

Identify the following rhythms

1.
2.
3.
4.
5.











Answers


1.
3rd degree heart block changing to ventricular standstill











The rhythm begins with complete heart block and changes to P wave asystole.   After the 2nd QRS complex there is a complete loss of ventricular activity and only P waves are seen.  With the loss of ventricular activity all cardiac output is loss.   Although there is a rhythm on the monitor,  the patient is now pulseless so immediate CPR is indicated.   Epinephrine and vasopressin may given but attention must be given to treating the underlying cause of this rhythm change.


2.
Ventricular paced with demand atrial pacing







The rhythm is regular with a heart rate of 60/min.  Some sinus P waves are seen as well as some atrial paced P waves, the 1st and 7th P waves.    The PR interval is prolonged on the sinus P waves.  The QRS complexes are preceded by a ventricular pacer spike.  PR:  .44 sec,  QRS:  .16 sec,  QT:  .48 sec.


3.
Atrial flutter










The rhythm is regular with a ventricular rate of 71/min.  There are flutter waves between the QRS complexes.   No ectopic beats are seen.  PR:  ---,  QRS:  .08 sec,  QT: .24 sec.


4.
Junctional rhythm








The rhythm is regular with a rate of 45/min.   The P waves are absent.   No ectopic beats are noted.   The QRS complex is narrow.   PR:  ---,  QRS:  .08 sec,  QT:  .44 sec.


5.
Ventricular fibrillation changing to asystole










The rhythm begins with a coarse ventricular fibrillation and transitions into asystole.   The treatment of choice for ventricular fibrillation is immediate defibrillation, however, with the change in the rhythm to aystole defibrillation is no longer an option.  Treatment of asystole includes high quality CPR, vasoconstrictors:  epinephrine or vasopressin, and investigation of reversible causes:  hypoxia,  hypovolemina,  acidosis,  hypothermia,  hyper/hypokalemia,  tension pneumothorax,  overdoses/poisioning, cardiac tamponade,  coronary thrombosis, or pulmonary embolism.


Reviewed 3/2/16

Wednesday, February 22, 2012

EKG Rhythm Strips 34

Identify the following rhythms.


1.
2.
3.
4.
5.










Answers


1.
NSR with ventricular bigemeny









The rhythm is irregular due to the multiple ectopic beats.   The ventricular rate is 96/min.   The P waves are positive and are associated with a QRS complex.   There are ectopic beats every other beat.   The character of these ectopic beats is different and there are some P waves present before some of the beats,  the 3rd and 4th ectopic beats.  These two ectopic beats may represent aberrantly conducted PACs.   PR:  .12 sec,  QRS:  .08 sec,  QT:  .32 sec.

2.
Ventricular fibrillation changing to asystole










The rhythm begins with fine ventricular fibrillation and deteriorates into aystole.   The treatment of asystole begins with high quality CPR:  adequate depth of compression,  at least 100/min,  minimizing interruptions,  and avoiding hyperventilation.   Attention should be given to treating reversible causes: hypoxia, hypovolemia, hydrogen ions (acidiosis), tamponade,  tension pneumothorax, and thrombosis (cornonary and pulmonary).  


3.
Sinus tachycardia with a wide QRS complex.








The rhythm is regular with a rate of 150//min.   There are small P waves before each QRS complex.  No ectopic beats are noted.  The QRS complex is wide.   PR:  .10 sec,  QRS:  .14 sec,  QT:  ---


4
Junctional rhythm with occasional PVC










The rhythm is irregular with a rate of 50/min.  The P waves are absent.   A single PVC is noted at the beginning of the rhythm strip.   PR:  ---,  QRS:  .10 sec,  QT:  .40 sec.


5.
Agonal rhythm











The rhythm is regular with wide, bizarre-looking QRS complexes.   No atrial activity is noted.   This rhythm is one of many PEA rhythms.   There will be a rhythm on the monitor but the patient will be pulseless.   In this case, immediate CPR is indicated.   Epinephrine may be given to maintain the heart rate and blood pressure.   The rescuer should give immediate attention to addressing any reversible causes that may have contributed to this rhythm.


Reviewed 3/1/16

Tuesday, February 21, 2012

EKG Rhythm Strips 33

Identify the following rhythms
1.
2.
3.
4.

5.










Answers


1.
Atrial fibrillation with multifocal PVCs








The rhythm is very irregular with a heart rate of 102/min.  No P waves are seen but there is some fibrillatory waves between the QRS complexes.   Multifocal PVCs are seen.   PR:  ---,  QRS:  .12 sec,  QT:  .36 sec.


2.
Junctional tachycardia








The rhythm is regular with a rate of 115/min.   The P waves are negative and precede the QRS complexes.   No ectopic beats are noted.  PR:  .12 sec,  QRS:  .08 sec,  QT:  .32 sec.


3.
Supraventricular tachycardia








The rhythm is regular with a ventricular rate of 188/min.  The P waves are not seen.    No ectopic beats are seen.   The QRS complex is narrow suggesting a supraventricular origin.   PR:  ---,  QRS: .08 sec,  QT:  .20 sec.


4.
Ventricular tachycardia changing to ventricular fibrillation










The rhythm is a regular monomorphic ventricular tachycardia but it deteriorates into a coarse ventricular fibrillation.   The primary treatment for the rhythm is immediate defibrillaton beginning at 200 J (biphasic).   CPR should be initiated immediately after the shock is delivered.   After two minutes evaluate the rhythm and if it is unchanged, deliver a 2nd shock at a higher energy level, usually 300 J and resume CPR.  Epinephrine or vasopressin may be given.  A third shock at the same or higher energy level may be given, usually 360 J followed by either another dose of the vasoconstrictors and an antiarrhytmic:  Amiodarone or lidocaine, if the amiodarone is unavailable.  Continue with high quality CPR and do a rhythm check every two minutes.  If the ventricular fibrillation remains, then continue to defibrillate at 360 J.   At all times, consider what reversible causes may have contributed to the rhythm and treat them accordingly.


5.
Accelerated junctional rhythm










The rhythm is regular with a rate of 83/min.   The P waves are absent.   No ectopic beats are noted.  PR:  ---,  QRS:  .08 sec,  QT:  .38 sec.



Reviewed 3/1/16