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Terms in this set (153)Elements of Effective High-Performance Team Dynamics 1. Clear Roles and Responsibilities Clear Roles and Responsibilities Every member should know his/her role and responsibilities. Resuscitation Triangle Roles Compressor Leadership Roles Team Leader Knowing Your Limitations Know your limitations, team leader should also know your limitations. Ask for advice when unsure. Constructive Intervention Leader may need to intervene if action may be inappropriate at the time. It should be tactful. Avoid confrontation. Knowledge Sharing Encourage an environment of knowledge sharing. Ask for good ideas for DDX. As if anything has been overlooked. Summarizing and Reevaluating Summarize information out load in a periodic update to the team. Review status of resuscitation attempt an announce plans for next steps Closed-Loop Communications Give clear
message, orders, or assignments to team members. Clear Message concise communication spoke with distinctive speech in controlled tone of voice Mutual Respect Share a mutual respect for each other and work together
Systematic Approach -If pt appears unconscious -If patient appears conscious BLS Assessment Check Responsiveness Shout for nearby help/activate Emergency response/AED/defibrillator Check breathing and pulse Defibrillation Check Responsiveness Tap and shout "Are you ok?" Shout for nearby help/activate Emergency response/AED/defibrillator Shout for nearby help Check breathing and pulse Check for absent or abnormal breathing by looking or scanning the chest for monument. for about 5-10 seconds Pulse check should be performed simultaneously with breathing check to minimize delay in detection of cardiac arrest and initiation of CPR Check pulse for 5-10 sec If no pulse within 10 sec begin CPR with chest compressions If there is a pulse start rescue breathing at 1 breath every 5-6 seconds. Check pulse every 2 minutes Defibrillation If no pulse, check for shockable rhythm Provide shocks as indicated Follow each show immediately with CPR beginning with compressions How long do you try to limit interruptions in chest compressions No longer than 10 seconds Coronary Perfusion Pressure (CPP) Aortic relaxation (diastolic) pressure - Right atrial relaxation (diastolic) pressure ROSC Return of Spontaneous Circulation When is ROSC most likely to occur When CPP of 15 mmHg or greater was achieved during CPR Chest Compression Concepts Compression of at least 2 inches Compress the chest at rate of 100-120/min Allow compete chest recoil after each compression The Primary Assessment Airway Breathing Circulation Disability Exposure Airway Maintain patent airway in unconscious patient using head tilt-chin lift, OPA or NPA Used advanced airway management if needed Breathing Give O2 when indicated Maintain O2 Sat of 94% or greater Monitor adequacy of ventilation and oxygenation Avoid excessive ventilation Circulation Monitor
CPR quality Attach monitor/defibrillator Provide defibrillator/cardioversion Obtain IV/IO Give appropriate drugs Give IV/IO fluids as needed Check glucose and temp Check perfusion issues Disability Check for neuro function Quickly assess responsiveness, Level of consciousness, pupil dilation AVPU: Alert, Voice, Painful, Unresponsive Exposure Remove clothing to perform a physical exam, looking for obvious sings of trauma, bleeding, burns, unusual markings, or medical alert brackets Secondary Assessment involves differential diagnosis, including focused history and search for underlying case. SAMPLE: Signs/Symptoms, Allergies, Medications, PMH, Last meal consumed, Events H's & T's Potential reversible causes of cardiac arrest as well as emergency cardiopulmonary conditions H's Hypovolemia T's Tension pneumothorax Most common causes of Pulseless Electrical Activity (PEA) Hypovolemia and Hypoxemia Hypovolemia Common cause of PEA, initially produces a rapid narrow-complex tachycardia, and typically increases diastolic and decreased systolic pressure. As blood loss continues, blood pressure drops, eventually becoming undetectable, but narrow QRS complexes and rapid rate continue (PEA) Respiratory Distress Clinical state characterized by abnormal respiratory rate or effort Respiratory Failure Clinical state of inadequate oxygenation, ventral or both. Often the end stage of Respiratory Distress. Respiratory Arrest Cessation of breathing. Usually caused by events such as drowning or head injury . Provide tidal volume approx 500-600 mL (6-7 mL/kg) Excessive ventilation can cause Gastric inflation Regurgitation and aspiration Increased intrathoracic pressure Decreased venous return to heart Diminished cardiac output and survival Bag-Mask Ventilation Deliver approximately 600 mL tidal volume to produce chest rise over 1 second Oropharyngeal Airway (OPA) Used in unconscious patient if chin lift or jaw thrust fails Should NOT be used in conscious or semiconscious patient How to select proper size OPA Place OPA against side of face, when flange of OPA is at corner of moth, the tip should be at the angle of the mandible Nasopharyngeal Airway (NPA) Used as alternative to OPA May be used in conscious, semiconscious or unconscious patients How to select proper size NPA Compare butter circumference of NPA with inner aperture of nare. Length of NPA should be same as distance from tip of patients nose to the earlobe. Soft Suctioning Aspiration of thin secretions fro oropharynx and nasopharynx Performing intratracheal suctioning Suctioning thought in-place airway (ie NPA) to access back of pharynx in pt with clenched teeth Rigid Suctioning More effective suction of the oropharynx, particularly if there is thick particulate matter (vomit) Types of Advanced Airway devices Laryngeal mask airway Ventilation rate of Advanced airway device Cardiac Arrest: Once every 6 seconds Respiratory Arrest: Once very 5-6 seconds ACS Algorithm STEMI Chain of Survival Rapid recognition and reaction to STEMI warning signs Rapid EMS dispatch and transport and prearrival notification to receiving hospital Rapid assessment and dx in the ED (or cath lab) Rapid treatment Administer O2 and drugs for ACS/Suspected STEMI Oxygen Aspirin Nitroglycerin Opiates (e.g. Morphine) Oxygen give if O2<90% Aspirin -160-325 mg of non-enteric coated. Have patient
chew them Nitroglycerin - 1 SL tablet or spray every 3-5 minutes. Morphine Given for chest discomfort unresponsive to nitro EKG Obtain within 10 minutes of arrival and assess the patient It is the center of decision pathway in management of ischemic chest discomfort and the only means to identify a STEMI Reperfusion goals for STEMi patients Fibrinolytic within 30 minutes of arrival or perform PCI within 90 minutes of arrival The 1st 10 minutes of assessing and stabilizing patient Check vitals STEMI ST-segment elevation in 2 or more contiguous leads or new LBBB. J-joint elevation greater than 2mm in leads V2 and V3 and 1mm or more in all other leads by new or presumed new LBBB 2.5 mm in men younger than 40 NSTE-ACS Ischemic ST-segment depression 0.5 mm or greater or dynamic T-wave inversion w/ pain or discomfort Low-/intermediate-risk ACS Normal or non diagnostic changes in T segment or T wave that are inconclusive and return future risk stratification St-segment deviation in either direction of less that 0.5 mm or T-wave inversion less than or equal 2mm. Mainstay tx for STEMI Early reperfusion therapy achieved with primary PCI or fibrinolytic Door to PCI Goal 90 minutes if at non-PCI-capable hospital, 120 minutes Door to Fibrinolytics 30 minutes Fibrinolytic Agent Clot buster, administered to pt with J-point ST segment elevation >2mm in leads V2 and V3, and 1 mm or more in all other leads or by new LBBB examples: rTPA, reteplase, tenecteplase Major types of Stroke Ischemic Stroke- MC Hemorrhagic stroke Stroke Chain of survival Rapid recognition and reaction to stroke warning signs Rapid EMS dispatch Rapid EMS system transport and prearrival notification Rapid diagnosis and tx in hospital 8 D's of Stroke Care 1. Detection NINDS in-hospital goals for assessment of suspect stroke 1. Immediate general assessment by the stroke team, emergency physical , or expert within 10 minutes of arrival, order surgery non contrast CT 2. Neurologic assessment by stroke team or designee and CT scan performed in 25 minutes of hospital arrival 3. Interpretation of the CT scan within 45 minutes of ED arrival 4. initial of fibrinolytic therapy in appropriate patients, within 1 hour of hospital arrival and 3 hours from symptom onset 5. Door to admission time of 3 hours Cincinnati Prehospital Stroke Scale Facial droop (have patient smile or try to show teeth) Arm Drift (have patient close eyes and hold both arms out, with palms up) Abnormal speech (have the patient say "you can't teach an old dog new tricks") Immediate General Assessment and Stabilization Assess ABCs Provide Oxygen Establish IV access and obtain blood samples Check Glucose Perform Neuro exam Activate stroke team Order CT scan Obtain 12 lead EKG Non contrast CT Scan Can differentiate between ischemic and hemorrhagic stroke. Most important test for a patient with acute stroke If Hemorrhage is present Pt not candidate for fibrinolytic No Hemorrhage Fibrinolytic, but if C/I give ASA Fibrinolytic Therapy Given to adults with acute ischemic stroke within 3 hours of onset of symptoms, or within 4.5 hours of onset of symptoms for selected patients Inclusion Criteria for fibrinolytic Dx of ischemic stroke causing neuro deficits Onset of symptoms <3 hours Age >18 years Exclusion criteria for Fibrinolytic Head trauma or stroke w/i 3 months Inclusion Criteria for fibrinolytic 3-4.5 hr ischemic stroke with neuro deficit Exclusion Criteria for Fibrinolytic 3-4.5 hr Age >80 Monitor Blood Glucose Consider giving IV or SQ insulin when glucose is greater than 185 mg/dL Hypertension managent in rtPA candidates Blood pressure must be 185 mmHg or less systolic and 110 mmHg or less Diastolic to limit risk of bleeding Medications for treatment of HTN in stroke pt Labetalol Labetalol dose 10-20 mg IV over 1-2 minutes, may repeat X 1 Nicardipine IV 5mg/hr, titrate up to 2.5 mg/h every 15-20 minutes, max 15 mg/hr Adult Cardiac Arrest Algorithm Antiarrhythmics Amiodarone Amiodarone Dose 300 mg IV/IO bolus, then consider additional 150 mg IV/IO once Class III Antiarrhythmic Lidocaine Dose Given if Amiodarone is unavailable 1-1.5 mg/kg IV/IO first dose, then 0.5 to 0.75 mg/kg IV/IO at 5-10 minute intervals Max dose of 3 mg/kg Magnesium Sulfate 1-2 g IV/IO diluted in 10 mL (D5W, NS) given as IV/IO bolus, typically over 5 to 20 minutes Persistently low PETCO2 values less than 10mmHg suggest ROSC is less likely to occur Sudden spike in ETCO2 of 35-40 mmHG Suggest ROSC has occurred In Asystole consider stopping CPR if ETCO2 is Less than 10 mmHg after 20 minute of CPR Symptomatic Bradycardia HR less than 50 w/ symptoms Cornerstone of managing bradycardia Differential beween S/S that are caused by the slow HR vs those that are unrelated Correctly diagnose presence and type of AV blocks Use Atropine as 1st line drug of choice Decide when to intimate Transcutaneous pacing (TCP) Decide when to start Eii or dopamine Know when to cal expert consult In addition: You must know the techniques and cautions for using TCP Sinus Bradycardia w/ borderline first-degree AV block Second-degree AV block type 1 (wenkebock) Second-degree AV block type 2 (Mobitz) Complete AV block w/ ventricular escape pacemaker Third-Degree AV bock w/ junctional escape pacemaker Adult Bradycardia With a Pulse Algorithm Atropine 0.5 mg IV may repeat to a total dose of 3 mg Dopamine Infusion 2 to 20 mcg/kg/min Epinephrine Infusion 2 to 10 mcg/min Avoid atropine in Type II second-degree or third-degree AV blocks . These bradyarythmias are not likely to respond to reversal of cholinergic effects, tx is TCP or B-adrenergic support Transcutaneous Pacing (TCP) Delivers pacing impulses to heart throughout the skin by use of cutaneous electrodes. When To use TCP 1. Hemodynamically unstable
bradycardia Precaution for TCP Contraindicated in severe hypothermia not recommended for Asystole Conscious patients require analgesia if time allows Do not assess carotid pulse to confirm mechanical capture, electrical stimulation causes muscular jerking that may mimic the carotid pulse Technique for TCP 1. Place pacing electrodes on chest Sinus tachycardia Atrial fibrillation Atrial flutter Supraventricular tachycardia Monomorphic ventricular tachycardia Polymorphic ventricular tachycardia 2 Keys to management of tachycardia 1. Rapid recognition that the patient is significantly symptomatic or even unstable 2. Rapid recognition that the S/S are caused by the tachycardia HR less than 150 is suggestive of unlikely that symptoms of instability are caused by the tachycardia HR greater than 150 usually inappropriate response to physiologic stress (fever, dehydration eat) or other underlying condition Adult Tachycardia with a Pulse Algorithm Unstable tachycardia Requires immediate cardioversion, even in the absence of EKG Most wide-complex tachycardias are... Ventricular in origin If pt unstable w/ pulse w/ regular uniform wide-complex vt Treat with synchronized cardioversion and initial shock of 100J (monophasic waveform) If no response to 1st shock, increase the dosage in a stepwise fashion Arrhythmias w/ polymorphic QRS appearance (polymorphic VT) Treat as VF w/ high-energy unsynchronized shock Unsynchronized Shock The electrical shock will be delivered as soon as operator pushes the shock button to discharge the device. These shocks use higher energy levels Synchronized Shock Uses a sensor to deliver a shock that is synchronized with a peak of the QRS complex When to use Synchronized Shocks Unstable VT Unstable a-fib Unstable a-flutter Unstable regular monomorphic tachycardia w/ pulse When to use unsynchronized shocks Patient who is pulseless Patient demonstrating clinical deterioration When you are unsure whether monomorphic or polymorphic VT is present Tx of choice when pt has symptomatic reentry SVT or VT with pulses Synchronized cardioversion Assessment of tachycardia w/ present pulse Perform BLS assessment and Primary and Secondary assessments. Determine if significant symptoms or sings are present and if they are due to the tachycardia If S/S of tachycardia are due to the tachycardia Pt is unstable and immediate cardioversion is indicated If pt develops pulseless vt deliver unsynchronized high-energy shocks and follow Cardiac arrest algorithm
Polymorphic VT Treat the rhythm as VT and deliver high-energy unsynchronized shocks Patient has stable tachycardia w/ pulse BLS, Primary, Secondary assessment Drugs to avoid in pt w/ Irregular Wide-complex tachycardia AV nodal blocking agents such as Adenosine, CCB, Digoxin and possibly B-Blockers Therapy for narrow QRS w/ regular rhythm is Attempt Vagal maneuvers Vagal maneuvers are preferred initial intervention for terminating narrow-complex tachycardia that are symptomatic (but stable) and supraventricular in origin Adenosine given if Vagal maneuvers fail 6mg rapid IV push over 1 second If SVT does not convert within 1-2 minutes Adenosine should generally not be given to Asthma or COPD patients Synchronized cardioversion for Narrow Regular 50-100 J Synchronized cardioversion for Narrow Irregular 120-200 J Synchronized cardioversion for Wide regular 100 J Synchronized cardioversion for Wide irregular Defibrillation dose NOT synchronized Antiarrhythmic Infusions for Stable Wide-Complex Tachycardia Procainamide Procainamide 20-50 mg/min until arrhythmia suppressed, hypotension ensures, QRS duration increased >50%, or maximum dose 17 mg/kg given Maintenance infusion: 1-4 mg/min Avoid of prolonged QT or CHF Amiodarone (Infusion dose) 1st dose: 150 mg over 10 min Follow by maintenance infusion of 1mg/min for first 6 hours Sotalol 100 mg (1.5 mg/kg) over 5 min. Avoid if prolonged QT Drugs for post-cardiac arrest care Epinephrine infusion Adult Immediate Post-Cardiac Arrest Care Algorithm Ventilation rate should be started at 10/min and titrated to achieve a PETCO2 of 35-40 mmHg or a PaCO2 of 40-45 mmHG Targeted Temperature Management Adults with ROSC after cardiac arrest, by selecting and maintaining a constant temperature between 32-36 degree C (89.6-95.2 degree F) for at least 24 hours Treat Hypotension (SBP Less than 90 mmHg) IV bolus Norepinephrine Epinephrine Dopamine IV Bolus for Hypotension 1-2 L normal saline or lactated Ringer's Norepinephrine 0.1-0.5 mcg/kg/min IV infusion titrated to achieve minimum SBP >90 mmHg or MAP >65 mmHg Epinephrine (for hypotension) 0.1-0.5 mcg/kg/min IV infusion titrated to achieve minimum SBP >90 mmHg or MAP >65 mmHg Dopamine 5-10 mcg/kg/min IV infusion titrated to achieve minimum SBP >90 mmHg or MAP >65 mmHg Sets with similar termsACLS32 terms elizabeth_sixkiller ACLS51 terms lesliephoto12 ACLS Practice84 terms Axelknows ACLS certification91 terms nicole_rae49 Sets found in the same folderACLS practice questions95 terms beauhunter02 Cardiology Flashcards (218)218 terms thepalifeTEACHER PANCE/PANRE Dermatology Blueprint Review58 terms thepalifeTEACHER Ear Disorders (PEARLS)17 terms thepalifeTEACHER Other sets by this creatorID Pharmacology46 terms jami_pollard Pharmacology30 terms jami_pollard Recommended textbook solutionsClinical Reasoning Cases in Nursing7th EditionJulie S Snyder, Mariann M Harding 2,512 solutions
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The best leaders manage their team's work. They plan, organize, delegate, arrange resources, and ensure the completion of the team's responsibilities.
What is a step of closed loop communication ACLS?By repeating back the verbal orders issued during a code, the loop of communication is closed. Closed-loop communication enables the person giving the orders to hear what they said reflected back and to confirm that their message was, in fact, received correctly.
What are the 3 signs of clinical deterioration that would cause activation of a rapid response system?Each healthcare institutions establish their criteria when to activate the rapid response team but most of these criteria include: Heart rate less than 40 beats per minute. Heart rate greater than 130 beats per minute. A change in the systolic blood pressure to less than 90 mmHg.
What is mutual respect in ACLS?Mutual Respect
To have a high-performance team, everyone must abandon ego and respect each other during the resuscitation attempt, regardless of any additional training or experience that the team leader or specific team members may have.
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