Monday, December 31, 2012

Code Blue: PEA


Near, far, wherever you are
 I believe that the heart does go on…


 09:53  Placed on monitor
Initial rhythm

09:55 CPR
Unsuccessful IV access attempt
Unsuccessful IV access attempt
CPR Rhythm


10:00 CPR
Intubated 7.5 ET tube. 
Tube placement confirmed
CPR Rhythm


10:02 Epinephrine 2mg via ET tube
Successful IO placement in right tibia
CPR in progress
CPR Rhythm


10:05 Vasopressin 40 units IO
CPR in progress
CPR Rhythm Check

10:09 Epinephrine 1mg IO
NS fluid bolus started
CPR Rhythm


10:11 Sodium Bicarbonate IO
CPR in progress
Adequate ventilations
CPR Rhythm Check


10:15 Epinephrine 1mg IO
CPR in progress
CPR Rhythm


10:19 Epinephrine 1mg IO
CPR in progress
CPR Rhythm Check

10:24 Epinephrine 1mg IO
CPR in progress
CPR Rhythm



10:27  Epinephrine 1mg IO
Continued CPR

Final rhythm


10:28  Code ended

Once more you open the door
And you're here in my heart
And my heart will go on and on…

(My Heart Will Go On by HORNER, JAMES / JENNINGS, WILL)

Sunday, December 30, 2012

Pediatric PEA Part 5

Pediatric PEA


Evaluate Reversible Causes
·         Hypoxia
·         Hypovolemia
·         Hyper/hypokalemia
·         Hypothermia
·         Tension pneumothorax
·         Tamponade
·         Thromboembolism
·         Tables/toxins
·         Trauma

Note:  Management of PEA is exactly the same as for asystole. Interventions for specific causes of PEA may lead to successful resuscitation. Appropriate measures may include a rapid fluid bolus for potential hypovolemia (20 mL/kg normal saline or lactated Ringer’s administered IV or IO), needle decompression for suspected tension pneumothorax, ventilation and sodium bicarbonate for acidosis, or pericardiocentesis for cardiac tamponade as regional protocols permit.

Reversible Causes of PEA
·         Hypoxia- use DOPE mnemonic
·         Hypovolemia- 20ml/kg fluid bolus
·         Hyper/hypokalemia- correct imbalance
·         Hypothermia- consider rewarming techniques

Note:  DOPE mnemonic- D: displacement of tube, 0: obstruction of tracheal tube, P: pneumothorax, E: Equipment failure
Management of PEA is exactly the same as for asystole. Interventions for specific causes of PEA may lead to successful resuscitation. Appropriate measures may include a rapid fluid bolus for potential hypovolemia (20 mL/kg normal saline or lactated Ringer’s administered IV or IO), needle decompression for suspected tension pneumothorax, ventilation and sodium bicarbonate for acidosis, or pericardiocentesis for cardiac tamponade as regional protocols permit.

Reversible Causes of PEA
·         Tension pneumothorax- needle decompression
·         Tamponade: pericardiocentesis
·         Tables/toxins: tx based on specific toxin
·         Thromboembolism: rare and difficult to treat

Note:  In tension pneumothorax, PEA results when air trapped within 1 side of the chest pushes the mediastinum toward the opposite side. If this shift is extreme, venous blood return to the heart is occluded by kinks in the great vessels above and below the mediastinum. The heart continues to contract, giving rise to normal electrical activity on cardiac monitoring, but no blood is entering the heart, so there is no palpable pulse.

In cardiac tamponade, PEA results when blood or other fluid fills the pericardial sac that surrounds the heart, preventing it from pumping normally and markedly decreasing cardiac output. When the ventricles contract during systole, the pressure between the pericardium and myocardium decreases and additional fluid enters the sac. When the ventricles relax during diastole, pressure from the fluid in the pericardial space prevents them from returning to their normal volume. This presents classically with hypotension, muffled heart sounds, and distended neck veins (Beck’s Triad); the latter two findings may be difficult to discern in infants.

Post-resuscitation
·         Maintain normal ventilation
·         Monitor temperature
·         Manage post-ischemic myocardial dysfunction
·         Maintain normal glucose

Ethical concerns
·         Family presence during resuscitation
·         Designated staff member should be available to support and remain with family during resuscitation
·         Positive psychological effects            
·         Planning, staff acceptance

Sources
PALS Provider Manual. American Heart Association 7272 Greenville Ave. Dallas, Tx 75231
PALS Provider Manual. American Heart Association 7272 Greenville Ave. Dallas, Tx 75231
Kleinman ME, Chameides L, Schexnayder SM, Samson RA, Hazinski MF, Atkins DL, Berg MD, de Caen AR, Fink EL, Freid EB, Hickey RW, Marino BS, Nadkarni VM, Proctor LT, Qureshi FA, Sartorelli K, Topjian A, van der Jagt EW, Zaritsky AL. Part 14: pediatric advanced life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(suppl 3):S876–S908



Saturday, December 29, 2012

Pediatric PEA Part 4

Pediatric PEA


Length based color-coded tape.


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

IV Access
·         Peripheral IV
·         Central line
·         Intraosseous
·         Endotratracheal


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



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


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

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

Vasoconstrictors
Epinephrine 0.01mg/kg (0.1ml/kg of a 1:10,100 solution) IV or IO
Epinephrine 0.1mg/kg (0.1ml of a 1:1000 solution) via ET tube
May repeat dose every 3-5 minutes

Note:  Epinephrine increases the heart rate and myocardial contractility more effectively than atropine through its alpha- and beta-adrenergic receptor stimulation. Its direct chronotropic effects (beta-agonist) and vasoconstrictor effects (alpha-agonist) increase mean arterial blood pressure, coronary perfusion pressure, and myocardial oxygen delivery. While epinephrine does increase myocardial oxygen consumption, it poses no significant risk of causing myocardial infarction in children as it does in adults.

Friday, December 28, 2012

Pediatric PEA Part 3

Pediatric PEA


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) + 3.5

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 

Thursday, December 27, 2012

Pediatric PEA part 2

Pediatric PEA Rhythms


Idioventricular rhythm



Sinus bradycardia







Sinus tachycardia with inverted T waves






Agonal Rhythm



PEA mnemonic:  Keep them ALIVE
Assess ABCs
Listen for pulse using doppler
Initiate CPR
Vasoconstrictors
Evaluate reversable causes

Assess ABCs- Primary Survey
·         Assess responsiveness and pulse
·         Active EMS system
·         Call for defibrillator/monitor

Note:  If a rhythm is present on the monitor but the pulse is absent (eg,PEA), CPR should be started immediately, beginning with chest compressions, and should continue for 2 minutes before the rhythm check is repeated.

Listen for Pulse Using Doppler
·         A doppler will help distinguish between a pulseless state and profoundly weak cardiac contractions with a low cardiac output (pseudo-PEA).
·         True PEA:  no pulse and no perfusion
·         Pseudo-PEA: weak pulse detected by doppler or echocardiography and severely compromised perfusion

Initiate 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

Wednesday, December 26, 2012

Pediatric PEA Part 1


Pediatric PEA

Pediatric 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

Pulseless Electrical Activity
·         Displays a rhythm on the monitor but does not have an arterial pulse
·         Confirm pulselessness with doppler
·         Key to treatment is CPR and early identification of possible causes
·         Outcome is very poor unless the cause can be established and treated
·         Pediatric patients who are in PEA do not benefit from defibrillation

Note:  The most common ECG findings in infants and children in cardiac arrest are asystole and PEA. PEA is organized electrical activity—most commonly slow, wide QRS complexes—without palpable pulses. Pulseless electrical activity (PEA), in which electrical activity is visible on the electrocardiogram but central pulses are absent (previously referred to as EMD)
Children with pulseless electrical activity are apneic with absent pulses and signs of poor perfusion. The electrocardiogram shows organized electrical activity, although no pulses are present. The outcome from PEA is very poor unless the cause can be established and treated

Tuesday, December 25, 2012

Pediatric cardiac arrest: PEA


1250:  A 10 year old boy is brought to the emergency room by EMS after he struck a tree with his three-wheeler.  On the scene he was conscious,  alert and oriented but in route he began to have increasing shortness of breath and was becoming more lethargic.  The EMTs initiated positive pressure ventilations in route to the hospital.    He is on a spinal board with a C collar in place.   When he is transferred from the EMS stretcher to the hospital stretcher is found to be unresponsive and he no longer has spontaneous respirations. 

1252:  No pulse is detected.  A pediatric code is called and CPR is initiated.  He is placed on the monitor and this is his initial rhythm. 

PEA rhythm

1255: CPR is continued.   A #20 IV is started in his right antecubtial fossa.  Epinephrine 1mg IV is given and and a fluid bolus of 20ml/kg is also started.  Because there is difficulty with providing positive pressure ventilations, the patient is intubated with a 6.5 cuffed ET tube. 

1255:  A review of his medical history is as follows

Symptoms:  no symptoms prior to accident.  A healthy 10 year old male child

Allergies:  allergic to Augmentin which causes a systemic rash

Medications: a daily chidlren's multivitamin

Past medical history: a tonsillectomy 2 years ago, seasonal allergies. 

Last meal eaten:  last oral intake estimated to be at 0800 that morning

Events:   His friends stated that he was driving racing his friend on his three-wheeler and lost control and hit a tree at high speed.  He was wearing a helmet at the time. 

1256:   Physical exam is as follows

Neuro:  unresponsive, Glasgow score of 8
EENT:  pupils nonreactive, no facial or head trauma
Neck: tracheal deviation to the left
Lungs:  Intubated with 6.5 ET tube.  Positive end tidal CO2 indicators.  Difficult to ventilate with positive pressure ventilations.   Auscultation of chest reveals good breath sounds on the right but decreased breath sounds on the left and no gurgling over the epigastrium.  There is asymmetrical chest rise. There is bruising and swelling on the left chest wall.  
Abdomen:  bruising on the left side of the upper abdomen.  Mild stomach distension.
Gentialia:  No bleeding from the urinary meatus.  A urinary catheter is being placed.  
Extremities:  Abrasions to left shoulder and arm.  Left shoulder is posteriorly displaced. Lower extremities unremarkable

Labs:  CBC, comprehensive metabolic panel, type and cross match
Radiology:  CXR, Left shoulder, clavicle, left arm.  CT head, neck, abdomen, and pelvis.  

1259:  CPR is in progress and epinephrine 0.01mg/kg is repeated.  A 2nd fluid bolus is initiated.    
CPR rhythm






13:01: Because of the tracheal deviation and asymmetrical chest rise, a needle decompression is performed which causes an immediate improvement in the ease of ventilations and the patient also begins to have symmetrical chest rise.   

1305:  CPR continues.  EpInephrine 0.01mg/kg is given.  

CPR rhythm






1308:  A rhythm check reveals a change in the patient’s rhythm
Sinus bradycardia without a pulse







1309:  The patient remains pulseless and apneic.  CPR is continued.
CPR rhythm






1310:  Another dose of epinephrine is given and another fluid bolus of 20mg/kg is ordered.   


1314:  Another rhythm check reveals the following rhythm.
Sinus tachycardia






1315:  At this time a carotid and brachial pulse are detected.   Vital signs:  97.2-120-20.   BP 84/54.   Oxygen saturation 93%.   The patient is beginning to have spontaneous, shallow respirations.   Positive pressure ventilations are continued and another fluid bolus of 20ml/kg is given.   Portable X-ray studies are completed at the bedside and preparations are being made to transport the patient to radiology for the CT studies.

Final diagnosis:
CT head and neck: negative
Left shoulder X-ray:  displaced fracture of the left clavicle and proximal humerus.
Chest x ray:  Pneumothorax and left 9-12 rib fractures. 
CT abdomen:  a splenic hematoma with contrast extravasation and some contrast pooling on delayed images with free fluid in the abdomen.
CBC:  Hgb 9.2 and HCT 10.3
Chemistries:  WNL
Type and Cross match: O positive blood.  








Monday, December 24, 2012

EKG Rhythm Strips 89

Identify the following rhythms
1.






2.

3.

4.

5.







Answers
1.  Atrial fibrillation with couplets
The rhythm is irregular with a rate of 80/min.   No P waves are present but fibrillatory activity can be seen betweeen the QRS complexes.  There are multifocal PVCs present, some in couplets.  PR: ---,  QRS:  .10 sec,  QT:  .36 sec.

2.  Bradycardia with 1st degree block.
The rate is 56/min.   The rhythm is regular.   There are upright, uniform P waves before each QRS complex.  No ectopic beats are present.  PR:  0.28 sec,  QRS:  .08 sec,  QT:  .42 sec.

3.  NSR with PACs.









The rhythm is irregular due to atrial ectopy.   The rate is  90/min.   There are upright P waves befoe each QRS complex.  Also, there is a small nonconducted P wave after the first PAC.   Premature atrial complexes are present.  PR:  .16 sec,  QRS:  .08 sec,  QT:  .40 sec.

4.  NSR with unifocal PVCs (trigeminy)
The rhythm is irregular due to the ectopic beats.   The rate is 70/min.   The P waves are positive and are associated with a QRS complex.   Premature ventricular complexes occur every 3rd beat.  PR:  .20 sec,  QRS:  .08 sec,  QT:  .36 sec.

5.  NSR with unifocal PVCs (trigeminy)
The rhythm is irregular due to the ectopic beats.   The rate is 60/min.   The P waves are positive and are associated with a QRS complex.   Unifocal PVCs occur in a trigeminal pattern.  PR:  .20 sec,  QRS:  .08 sec,  QT:  .44 sec.


Reviewed 3/9/16

Sunday, December 23, 2012

Basic ECG Rhythm Test 03

EKG Rhythm Practice Test

Identify the following rhythms.

1.













2.














3.














4.














5.













6.














7.














8.













9.













10.














11.













12.













13.


14.


15.















16.















17.



18.














19.












20.


21.


22.










23.










24.



25.















For another Basic EKG Rhythm Test Click Here


Answers

1.    2nd degree heart block type I
2.    Agonal rhythm
3.    Atrial fibrillation with a PVC
4.    Biventricular pacing with a PVC
5.    Idioventricular rhythm
6.    Normal sinus rhythm with PJCs
7.    Normal sinus rhythm with multifocal PVCs
8.    Sinus tachycardia
9.    Torsades de pointe
10.  Ventricular fibrillation
11.  Junctional tachycardia
12.  Accelerated idioventricular rhythm
13.  2nd degree heart block type II
14.  Accelerated junctional rhythm
15.  Asystole
16.  Atrial flutter
17.  Complete heart block
18.  Junctional rhythm
19.  Normal sinus rhythm with triplet of PVCs
20.  Normal sinus rhythm with a PAC
21.  Normal sinus rhythm with ventricular bigeminy
22.  Sinus bradycardia
23.  Supraventricular tachycardia
24.  Polymorphic ventricular tachycardia
25.  Monomorphic ventricular tachycardia

Reviewed 3/9/16